Provider Demographics
NPI:1568460061
Name:PETERSON, ANDREW CRAIG (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:CRAIG
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:PO BOX 3178
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52406-3178
Mailing Address - Country:US
Mailing Address - Phone:319-398-1583
Mailing Address - Fax:319-399-2085
Practice Address - Street 1:202 10TH STREET SE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52403-2404
Practice Address - Country:US
Practice Address - Phone:319-398-1721
Practice Address - Fax:319-399-2016
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA283412084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA56483OtherBLUE CROSS/BLUE SHIELD
IA3075358Medicaid
IA3075358Medicaid
IA56483Medicare ID - Type Unspecified