Provider Demographics
NPI:1396853107
Name:PETERSON, JOANNE (MD)
Entity Type:Individual
Prefix:
First Name:JOANNE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JOANNE
Other - Middle Name:
Other - Last Name:KRAMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4735 WEST RIVER DR NE
Mailing Address - Street 2:
Mailing Address - City:COMSTOCK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:49321-9607
Mailing Address - Country:US
Mailing Address - Phone:616-784-9400
Mailing Address - Fax:616-784-5167
Practice Address - Street 1:4735 W RIVER DR NE
Practice Address - Street 2:
Practice Address - City:COMSTOCK PARK
Practice Address - State:MI
Practice Address - Zip Code:49321-9607
Practice Address - Country:US
Practice Address - Phone:616-784-9400
Practice Address - Fax:616-784-5167
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301074292208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5214331Medicaid