Provider Demographics
NPI:1841587854
Name:PETERSEN, JOHN ROGER (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ROGER
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:301 UNIVERSITY BLVD
Mailing Address - Street 2:RM 5.156 JSA
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77555-0551
Mailing Address - Country:US
Mailing Address - Phone:409-772-1350
Mailing Address - Fax:409-772-9231
Practice Address - Street 1:301 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77555-0551
Practice Address - Country:US
Practice Address - Phone:409-772-1350
Practice Address - Fax:409-772-9231
Is Sole Proprietor?:No
Enumeration Date:2011-06-29
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physician