Provider Demographics
NPI:1184998585
Name:PETERSEN, JEFFREY MING (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:MING
Last Name:PETERSEN
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 1:3900 WOODLAND AVE
Mailing Address - Street 2:DEPARTMENT OF PATHOLOGY AND LABORATORY MEDICINE
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104
Mailing Address - Country:US
Mailing Address - Phone:626-274-6485
Mailing Address - Fax:
Practice Address - Street 1:10833 LE CONTE AVE
Practice Address - Street 2:13-145A CENTER FOR HLTH SCI
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-3075
Practice Address - Country:US
Practice Address - Phone:626-274-6485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-02
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD459596207ZB0001X, 207ZP0102X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZB0001XAllopathic & Osteopathic PhysiciansPathologyBlood Banking & Transfusion Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program