Provider Demographics
NPI:1306826854
Name:PETERSON, ANDREW J (DO)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:J
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:147 REYNOIR STREET
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39530
Mailing Address - Country:US
Mailing Address - Phone:228-374-2051
Mailing Address - Fax:228-374-5741
Practice Address - Street 1:147 REYNOIR STREET
Practice Address - Street 2:SUITE 101
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39530
Practice Address - Country:US
Practice Address - Phone:228-374-2051
Practice Address - Fax:228-374-5741
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102201779207R00000X
MS20037207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01977252Medicaid