Provider Demographics
NPI:1417957234
Name:PETERSON, JOHN L (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:L
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:PO BOX 3710
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28603-3710
Mailing Address - Country:US
Mailing Address - Phone:828-324-9550
Mailing Address - Fax:828-324-4154
Practice Address - Street 1:2406 CENTURY PLACE
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28603
Practice Address - Country:US
Practice Address - Phone:828-324-9550
Practice Address - Fax:828-324-4154
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH15487207RH0003X
VT042-0012323207RH0003X
NC38166207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1019968Medicaid
NH32001131Medicaid
NC8967241Medicaid
NH32001131Medicaid
NH002525703Medicare PIN
NH002525702Medicare PIN
VT1019968Medicaid
D99402Medicare UPIN
NC8967241Medicaid