Provider Demographics
NPI:1407870975
Name:PETERSON, JON T (MD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:T
Last Name:PETERSON
Suffix:
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 1:2871 GREENSBORO RD
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-8108
Mailing Address - Country:US
Mailing Address - Phone:276-638-2273
Mailing Address - Fax:
Practice Address - Street 1:2871 GREENSBORO RD
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-8108
Practice Address - Country:US
Practice Address - Phone:276-638-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101052027207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8906672Medicaid
VA1407870975Medicaid
VA010064325Medicaid
004304E50Medicare PIN
VA1407870975Medicaid
VA00Y150M01Medicare PIN