Provider Demographics
NPI:1023239753
Name:PETERSON, JOHN DALE (DO)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:DALE
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 356
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67201-0356
Mailing Address - Country:US
Mailing Address - Phone:844-468-9498
Mailing Address - Fax:855-630-1302
Practice Address - Street 1:929 N SAINT FRANCIS ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-3821
Practice Address - Country:US
Practice Address - Phone:800-374-5326
Practice Address - Fax:800-374-7656
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2025-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0531672207L00000X, 207LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200611100AMedicaid
KS200611100BMedicaid
KSP00727380OtherRR MEDICARE GROUP CQ2302
KSP00727380OtherRR MEDICARE GROUP CQ2302
KS110017033Medicare PIN