Provider Demographics
NPI:1659450005
Name:PETERSON, JONATHAN B (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:B
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 1:500 W 144TH AVE STE 140
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80023-9326
Mailing Address - Country:US
Mailing Address - Phone:303-430-2640
Mailing Address - Fax:303-430-2625
Practice Address - Street 1:500 W 144TH AVE STE 140
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80023-9326
Practice Address - Country:US
Practice Address - Phone:303-430-2640
Practice Address - Fax:303-430-2625
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO41487207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000178662Medicaid
CO91120551Medicaid