Provider Demographics
NPI:1760452189
Name:PETERSON, JOHN M (PHD, MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:M
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PHD, MD
Other - Prefix:
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Mailing Address - Street 1:600 JOHN DEERE ROAD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6897
Mailing Address - Country:US
Mailing Address - Phone:309-779-4200
Mailing Address - Fax:309-779-4305
Practice Address - Street 1:600 JOHN DEERE ROAD
Practice Address - Street 2:SUITE 200
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6897
Practice Address - Country:US
Practice Address - Phone:309-779-4200
Practice Address - Fax:309-779-4305
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2008-06-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL036051289207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL110028700OtherRR MEDICARE
IL110028700OtherRR MEDICARE
ILP12137Medicare ID - Type Unspecified
ILC44209Medicare UPIN