Provider Demographics
NPI:1659383008
Name:PETERSON, RICHARD JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:JAMES
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:5304 4TH AVENUE CIR E
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34208-5624
Mailing Address - Country:US
Mailing Address - Phone:941-744-2640
Mailing Address - Fax:941-744-2650
Practice Address - Street 1:623 39TH ST W
Practice Address - Street 2:SUITE 2
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34205-2408
Practice Address - Country:US
Practice Address - Phone:941-744-2640
Practice Address - Fax:941-744-2650
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME58291208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE36305Medicare UPIN