Provider Demographics
NPI:1508880642
Name:PETERSON, JOHN CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CHARLES
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 1:100 N TILLOTSON AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-3987
Mailing Address - Country:US
Mailing Address - Phone:765-282-7475
Mailing Address - Fax:
Practice Address - Street 1:100 N TILLOTSON AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-3987
Practice Address - Country:US
Practice Address - Phone:765-282-7475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10027232207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100106190AMedicaid
IN204010Medicare ID - Type Unspecified
IN100106190AMedicaid