Provider Demographics
NPI:1639147606
Name:PETERSON, DAVID ANDREW JR
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:ANDREW
Last Name:PETERSON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 HICKORY ST
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-4634
Mailing Address - Country:US
Mailing Address - Phone:860-514-5293
Mailing Address - Fax:
Practice Address - Street 1:NOMI DET NUMI SUBMARINE BASE NLON
Practice Address - Street 2:BUILDING 159
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06349
Practice Address - Country:US
Practice Address - Phone:860-694-2876
Practice Address - Fax:860-694-3874
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
Provider Identifiers
StateIdentifier IDID TypeIssuer
1710I1002XOtherINDEPENDENT DUTY CORPSMAN