Provider Demographics
NPI:1659338812
Name:PETERSON, JAMES H (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:H
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 1:2528 W 16TH ST
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-4955
Mailing Address - Country:US
Mailing Address - Phone:970-356-4646
Mailing Address - Fax:970-356-2041
Practice Address - Street 1:2528 W 16TH ST
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-4955
Practice Address - Country:US
Practice Address - Phone:970-356-4646
Practice Address - Fax:970-356-2041
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO18035207Y00000X
OH35089116207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01180355Medicaid
OH2996978Medicaid
CO65124Medicare ID - Type Unspecified
OH4279121Medicare PIN
D23374Medicare UPIN