Provider Demographics
NPI:1710949474
Name:PETERSEN, BRUCE NORMAN (DO)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:NORMAN
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 MAIN ST W
Mailing Address - Street 2:SUITE A
Mailing Address - City:OAK HILL
Mailing Address - State:WV
Mailing Address - Zip Code:25901-2943
Mailing Address - Country:US
Mailing Address - Phone:304-465-0544
Mailing Address - Fax:304-465-8832
Practice Address - Street 1:119 MAIN ST W
Practice Address - Street 2:SUITE A
Practice Address - City:OAK HILL
Practice Address - State:WV
Practice Address - Zip Code:25901-2943
Practice Address - Country:US
Practice Address - Phone:304-465-0544
Practice Address - Fax:304-465-8832
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV0941207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0084786001Medicaid
WV0084786001Medicaid
E28896Medicare UPIN