Provider Demographics
NPI:1790032530
Name:PETERSEN, KYLE (DO)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:
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 1:3157 N UNIVERSITY DR STE 101
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33024-2258
Mailing Address - Country:US
Mailing Address - Phone:754-206-8250
Mailing Address - Fax:754-206-8260
Practice Address - Street 1:3157 N UNIVERSITY DR STE 101
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33024-2258
Practice Address - Country:US
Practice Address - Phone:754-206-8250
Practice Address - Fax:754-206-8260
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-10
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS11815207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine