Provider Demographics
NPI:1922092733
Name:PETERSEN, KENNETH D (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:D
Last Name:PETERSEN
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 1:1111 LIGHTHOUSE LANE
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-3824
Mailing Address - Country:US
Mailing Address - Phone:574-533-0348
Mailing Address - Fax:574-533-0277
Practice Address - Street 1:1111 LIGHTHOUSE LANE
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-3824
Practice Address - Country:US
Practice Address - Phone:574-533-0348
Practice Address - Fax:574-533-0277
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01028273207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
C24663Medicare UPIN
223710CMedicare ID - Type Unspecified