Provider Demographics
NPI:1912211905
Name:PETERKIN, NICHOLAS D A (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:D A
Last Name:PETERKIN
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 45443
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84145-0443
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-376-4107
Practice Address - Street 1:832 A1A N STE 6
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32082-3216
Practice Address - Country:US
Practice Address - Phone:904-834-3793
Practice Address - Fax:904-390-7435
Is Sole Proprietor?:No
Enumeration Date:2010-08-02
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME114121207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01346898OtherRAILROAD MEDICARE
FLHW196ZMedicare PIN