Provider Demographics
NPI:1417256272
Name:PETERSON, KYLE S (DPM)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:S
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 W SCHICK RD
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:IL
Mailing Address - Zip Code:60103-3007
Mailing Address - Country:US
Mailing Address - Phone:630-372-1100
Mailing Address - Fax:614-895-8810
Practice Address - Street 1:1110 W SCHICK RD
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:IL
Practice Address - Zip Code:60103-3007
Practice Address - Country:US
Practice Address - Phone:630-372-1100
Practice Address - Fax:630-483-0852
Is Sole Proprietor?:No
Enumeration Date:2011-03-19
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC006240213ES0103X
IL016005623213ES0103X
OH36003642213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PASC006240OtherSTATE PODIATRIC LICENSE NUMBER