Provider Demographics
NPI:1477528230
Name:PETERSON, JEFFREY ELAM (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:ELAM
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 1:6801 W 20TH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634
Mailing Address - Country:US
Mailing Address - Phone:970-378-8000
Mailing Address - Fax:970-378-8088
Practice Address - Street 1:6801 W 20TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634
Practice Address - Country:US
Practice Address - Phone:970-378-8000
Practice Address - Fax:970-378-8088
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO35796207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01357961Medicaid
G75155Medicare UPIN
CO01357961Medicaid