Provider Demographics
NPI:1922094952
Name:PETERSON, I EUGENE (MD)
Entity Type:Individual
Prefix:DR
First Name:I
Middle Name:EUGENE
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 4907
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50306-4907
Mailing Address - Country:US
Mailing Address - Phone:515-241-5785
Mailing Address - Fax:515-241-4415
Practice Address - Street 1:3901 INGERSOLL AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50312-3505
Practice Address - Country:US
Practice Address - Phone:515-274-9135
Practice Address - Fax:515-274-3107
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA18425207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAE59900Medicare UPIN