Provider Demographics
NPI:1508858861
Name:PETERSON, RICHARD KENNETH (MD)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:KENNETH
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 1:2627 RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-4712
Mailing Address - Country:US
Mailing Address - Phone:904-308-7372
Mailing Address - Fax:904-308-2998
Practice Address - Street 1:2627 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4712
Practice Address - Country:US
Practice Address - Phone:904-308-7372
Practice Address - Fax:904-308-2998
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0067446207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5562171-001OtherCIGNA
FL26755OtherBCBS
FL379680900Medicaid
FL4653879OtherAETNA
FL148899OtherHEALTHEASE
FL080119192OtherMEDICARE RAILROAD
FL26755OtherBCBS
FL4653879OtherAETNA