Provider Demographics
NPI:1821182072
Name:PETERSON, GEORGE WILLIAM (DO)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:WILLIAM
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:190 FREDON MARKSBORO RD
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07860-5012
Mailing Address - Country:US
Mailing Address - Phone:973-383-3062
Mailing Address - Fax:973-383-3840
Practice Address - Street 1:113 MAIN ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:NJ
Practice Address - Zip Code:07860-2037
Practice Address - Country:US
Practice Address - Phone:973-383-0808
Practice Address - Fax:973-383-3840
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB03775400207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2058201Medicaid
NJE06155Medicare UPIN
NJ2058201Medicaid