Provider Demographics
NPI:1942397799
Name:PETERSON, GEORGE DWIGHT (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:DWIGHT
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 1:5450 MACDONALD AVENUE
Mailing Address - Street 2:SUITE 12
Mailing Address - City:KEY WEST
Mailing Address - State:FL
Mailing Address - Zip Code:33040
Mailing Address - Country:US
Mailing Address - Phone:305-293-9555
Mailing Address - Fax:305-293-9415
Practice Address - Street 1:5450 MACDONALD AVENUE
Practice Address - Street 2:SUITE 12
Practice Address - City:KEY WEST
Practice Address - State:FL
Practice Address - Zip Code:33040
Practice Address - Country:US
Practice Address - Phone:305-293-9555
Practice Address - Fax:305-293-9415
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0065007174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL373887600Medicaid
FL373887600Medicaid