Provider Demographics
NPI:1730295163
Name:PETERSON, GAYLE E (MD)
Entity Type:Individual
Prefix:
First Name:GAYLE
Middle Name:E
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 1:211 N ENGDAHL AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68045-1431
Mailing Address - Country:US
Mailing Address - Phone:402-685-5116
Mailing Address - Fax:402-685-5817
Practice Address - Street 1:211 N ENGDAHL AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:NE
Practice Address - Zip Code:68045-1431
Practice Address - Country:US
Practice Address - Phone:402-685-5116
Practice Address - Fax:402-685-5817
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE11511207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
30849OtherBCBS
272707Medicare ID - Type Unspecified
30849OtherBCBS