Provider Demographics
NPI:1689637993
Name:PETERSON, GILMAN P JR (MD)
Entity Type:Individual
Prefix:
First Name:GILMAN
Middle Name:P
Last Name:PETERSON
Suffix:JR
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 1:109 BRAVO BLVD
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141-3412
Mailing Address - Country:US
Mailing Address - Phone:270-651-8328
Mailing Address - Fax:270-651-1731
Practice Address - Street 1:109 BRAVO BLVD
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-3412
Practice Address - Country:US
Practice Address - Phone:270-651-8328
Practice Address - Fax:270-651-1731
Is Sole Proprietor?:No
Enumeration Date:2006-04-08
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY20017208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64200173Medicaid
KY64200173Medicaid
KYC69234Medicare UPIN