Provider Demographics
NPI:1891766812
Name:PETERSON, HUBERT (MD)
Entity Type:Individual
Prefix:
First Name:HUBERT
Middle Name:
Last Name:PETERSON
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:PO BOX 1258
Mailing Address - Street 2:
Mailing Address - City:LIBERAL
Mailing Address - State:KS
Mailing Address - Zip Code:67905-1258
Mailing Address - Country:US
Mailing Address - Phone:620-626-8500
Mailing Address - Fax:
Practice Address - Street 1:1436 N WESTERN AVE
Practice Address - Street 2:
Practice Address - City:LIBERAL
Practice Address - State:KS
Practice Address - Zip Code:67901-2212
Practice Address - Country:US
Practice Address - Phone:620-626-8500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-22995207ZP0102X, 207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Not Answered207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D17043Medicare UPIN