Provider Demographics
NPI:1730127564
Name:PETERSON, PAUL III (DO)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:
Last Name:PETERSON
Suffix:III
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:PO BOX 310
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08350-0310
Mailing Address - Country:US
Mailing Address - Phone:856-697-0300
Mailing Address - Fax:856-697-8944
Practice Address - Street 1:761 S HARDING HWY
Practice Address - Street 2:
Practice Address - City:BUENA
Practice Address - State:NJ
Practice Address - Zip Code:08310-9732
Practice Address - Country:US
Practice Address - Phone:856-697-0111
Practice Address - Fax:856-697-0003
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB03868000207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1730127564OtherMEDICARE NPI
NJ1659308Medicaid
NJD80312Medicare UPIN
NJ1659308Medicaid