Provider Demographics
NPI:1790786895
Name:PETERSEN, JOHN PETER (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:PETER
Last Name:PETERSEN
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 1:3555 10TH CT
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-5013
Mailing Address - Country:US
Mailing Address - Phone:772-794-3333
Mailing Address - Fax:772-569-6949
Practice Address - Street 1:3555 10TH COURT
Practice Address - Street 2:INDIAN RIVER REGIONAL CANCER CENTER, IRMC
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-4862
Practice Address - Country:US
Practice Address - Phone:772-794-3333
Practice Address - Fax:772-569-6949
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 648482085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
920004346OtherMEDICARE RR
FL374792100Medicaid
FL23453AMedicare ID - Type Unspecified
FL374792100Medicaid