Provider Demographics
NPI:1598706525
Name:PETERSON, RAGNAR S (MD)
Entity Type:Individual
Prefix:DR
First Name:RAGNAR
Middle Name:S
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:RAGNAR
Other - Middle Name:S
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 8035
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-0035
Mailing Address - Country:US
Mailing Address - Phone:316-689-9135
Mailing Address - Fax:
Practice Address - Street 1:1947 N FOUNDERS CIR
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-3548
Practice Address - Country:US
Practice Address - Phone:316-613-4707
Practice Address - Fax:316-613-4608
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA36192208600000X
WI61452-20208600000X
KS04-34133208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000000215Medicare Oscar/Certification
KS003719461Medicare PIN
WIK400122049Medicare Oscar/Certification