Provider Demographics
NPI:1558353540
Name:PETERSEN, DAVID P (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:P
Last Name:PETERSEN
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 1:1111 LEFFINGWELL AVE NE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-6406
Mailing Address - Country:US
Mailing Address - Phone:616-957-4263
Mailing Address - Fax:616-957-0444
Practice Address - Street 1:1111 LEFFINGWELL AVE NE
Practice Address - Street 2:SUITE 200
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-6406
Practice Address - Country:US
Practice Address - Phone:616-957-4263
Practice Address - Fax:616-957-0444
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301039798208600000X, 2086S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the Hand
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4096458Medicaid
E39585Medicare UPIN
MI0D14869056Medicare PIN