Provider Demographics
NPI:1841203197
Name:PETERSEN, RICHARD ALPHONSO (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:ALPHONSO
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:RICHARD
Other - Middle Name:ALPHONSO
Other - Last Name:PETERSEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:6200 SUNSET DR
Mailing Address - Street 2:SUITE 502
Mailing Address - City:SOUTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-4828
Mailing Address - Country:US
Mailing Address - Phone:786-497-4480
Mailing Address - Fax:786-497-4485
Practice Address - Street 1:6200 SUNSET DR
Practice Address - Street 2:SUITE 502
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-4828
Practice Address - Country:US
Practice Address - Phone:786-497-4480
Practice Address - Fax:786-497-4485
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 62814207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL374033100Medicaid
FL542129332OtherTAX ID NUMBER
FL18339WMedicare ID - Type UnspecifiedPROVIDER NUMBER
FLE48614Medicare UPIN