Provider Demographics
NPI:1003833625
Name:PETERSON, JOHN (MD)
Entity type:Individual
Prefix:
First Name:JOHN
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 1:2917 CROSSING CT
Mailing Address - Street 2:SUITE B1
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-6184
Mailing Address - Country:US
Mailing Address - Phone:217-344-2740
Mailing Address - Fax:217-344-2819
Practice Address - Street 1:2917 CROSSING CT
Practice Address - Street 2:SUITE B1
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-6184
Practice Address - Country:US
Practice Address - Phone:217-344-2740
Practice Address - Fax:217-344-2819
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2019-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036083081207P00000X, 207RA0401X, 207R00000X, 207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036083081Medicaid
IL036083081Medicaid
ILK02719Medicare PIN