Provider Demographics
NPI:1013370568
Name:PETERSEN, ALEC
Entity Type:Individual
Prefix:
First Name:ALEC
Middle Name:
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 SW 149TH AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-4166
Mailing Address - Country:US
Mailing Address - Phone:617-732-6660
Mailing Address - Fax:617-975-0985
Practice Address - Street 1:880 SW 145TH AVE STE 202
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33027-6171
Practice Address - Country:US
Practice Address - Phone:615-275-6612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-01
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN67960207R00000X
OH35.144623207R00000X
AL45918207R00000X
390200000X
IL036167875207R00000X
NC2021-02940207R00000X
TXT5434207R00000X
FLME145182207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program