Provider Demographics
NPI:1639468887
Name:PETERSEN, TIMOTHY C (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:C
Last Name:PETERSEN
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 1:860 OMNI BLVD
Mailing Address - Street 2:STE 303
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-4434
Mailing Address - Country:US
Mailing Address - Phone:757-232-8769
Mailing Address - Fax:757-232-8875
Practice Address - Street 1:100 CONSTITUTION DR
Practice Address - Street 2:STE 217
Practice Address - City:VA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-6799
Practice Address - Country:US
Practice Address - Phone:757-963-1488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-28
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0101260679207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program