Provider Demographics
NPI:1568460590
Name:PETERSEN, HORACE REX (DO)
Entity Type:Individual
Prefix:DR
First Name:HORACE
Middle Name:REX
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:4040 LA QUESTA DR
Mailing Address - Street 2:
Mailing Address - City:NEOSHO
Mailing Address - State:MO
Mailing Address - Zip Code:64850-2849
Mailing Address - Country:US
Mailing Address - Phone:417-451-1833
Mailing Address - Fax:417-451-1825
Practice Address - Street 1:4040 LA QUESTA DR
Practice Address - Street 2:
Practice Address - City:NEOSHO
Practice Address - State:MO
Practice Address - Zip Code:64850-2849
Practice Address - Country:US
Practice Address - Phone:417-451-1833
Practice Address - Fax:417-451-1825
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOR9N57207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO13190OtherBLUE CROSS
MOE83682Medicare UPIN