Provider Demographics
NPI:1538284567
Name:PETERSON, MATTHEW DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:DAVID
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 1:101 HOSPITAL BLVD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130
Mailing Address - Country:US
Mailing Address - Phone:812-282-3899
Mailing Address - Fax:812-282-4172
Practice Address - Street 1:101 HOSPITAL BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130
Practice Address - Country:US
Practice Address - Phone:812-282-3899
Practice Address - Fax:812-282-4172
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01059355A208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP00419878OtherRR MCR
INP00432850OtherRR MCR
KY7100008390Medicaid
IN122620WMedicare PIN
KYP00419878OtherRR MCR
INP00432850OtherRR MCR