Provider Demographics
NPI:1376515726
Name:PETERSON, JAY T SR (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:T
Last Name:PETERSON
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6429 HIGH DR
Mailing Address - Street 2:
Mailing Address - City:MISSION HILLS
Mailing Address - State:KS
Mailing Address - Zip Code:66208-1935
Mailing Address - Country:US
Mailing Address - Phone:913-722-5825
Mailing Address - Fax:
Practice Address - Street 1:6429 HIGH DR
Practice Address - Street 2:
Practice Address - City:MISSION HILLS
Practice Address - State:KS
Practice Address - Zip Code:66208-1935
Practice Address - Country:US
Practice Address - Phone:913-722-5825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-14230207RH0003X
MOR6888207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOC51880Medicare UPIN