Provider Demographics
NPI:1528036142
Name:PETERSON, RENE A (DPM)
Entity Type:Individual
Prefix:DR
First Name:RENE
Middle Name:A
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:35202 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:MILLVILLE
Mailing Address - State:DE
Mailing Address - Zip Code:19967-6901
Mailing Address - Country:US
Mailing Address - Phone:302-541-0323
Mailing Address - Fax:302-539-8736
Practice Address - Street 1:35202 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:MILLVILLE
Practice Address - State:DE
Practice Address - Zip Code:19967
Practice Address - Country:US
Practice Address - Phone:302-541-0323
Practice Address - Fax:302-539-8736
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEE10000129213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000957917Medicaid
DE0000957917Medicaid
DEU75149Medicare UPIN