Provider Demographics
NPI:1023251840
Name:PETERSEN, JUDY JONES (DO)
Entity type:Individual
Prefix:
First Name:JUDY
Middle Name:JONES
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 MORRIS ST
Mailing Address - Street 2:SUITE 304
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1842
Mailing Address - Country:US
Mailing Address - Phone:304-388-7782
Mailing Address - Fax:304-388-7788
Practice Address - Street 1:600 MORRIS ST
Practice Address - Street 2:SUITE 103
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1409
Practice Address - Country:US
Practice Address - Phone:304-388-7040
Practice Address - Fax:304-388-7041
Is Sole Proprietor?:No
Enumeration Date:2009-04-08
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WV1108207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVP0106337OtherMEDICARE RAILROAD
WV0041503000Medicaid
WVWV0345AMedicare PIN