Provider Demographics
NPI:1023085917
Name:PETERSEL, KENNETH H (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:H
Last Name:PETERSEL
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 1:1617 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:EAST MEADOW
Mailing Address - State:NY
Mailing Address - Zip Code:11554-2345
Mailing Address - Country:US
Mailing Address - Phone:516-794-1330
Mailing Address - Fax:
Practice Address - Street 1:1617 FRONT ST
Practice Address - Street 2:
Practice Address - City:EAST MEADOW
Practice Address - State:NY
Practice Address - Zip Code:11554-2345
Practice Address - Country:US
Practice Address - Phone:516-794-1330
Practice Address - Fax:516-794-1531
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY137623207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00659389Medicaid
NY00659389Medicaid
NYB12138Medicare UPIN