Provider Demographics
NPI:1568564243
Name:PETERSON, TIMOTHY N (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:N
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 1:7945 S SUNCOAST BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:HOMOSASSA
Mailing Address - State:FL
Mailing Address - Zip Code:34446-5005
Mailing Address - Country:US
Mailing Address - Phone:352-382-5000
Mailing Address - Fax:352-382-1940
Practice Address - Street 1:7945 S SUNCOAST BLVD
Practice Address - Street 2:
Practice Address - City:HOMOSASSA
Practice Address - State:FL
Practice Address - Zip Code:34446-5005
Practice Address - Country:US
Practice Address - Phone:352-382-5000
Practice Address - Fax:352-382-1940
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME80717207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL259538900Medicaid
FLG92685Medicare UPIN
FL259538900Medicaid