Provider Demographics
NPI:1255391983
Name:PETERSON, KIRK KEVIN (MD)
Entity type:Individual
Prefix:
First Name:KIRK
Middle Name:KEVIN
Last Name:PETERSON
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 1:305 S US HIGHWAY 69
Mailing Address - Street 2:
Mailing Address - City:HUXLEY
Mailing Address - State:IA
Mailing Address - Zip Code:50124-8095
Mailing Address - Country:US
Mailing Address - Phone:515-597-2600
Mailing Address - Fax:515-597-3945
Practice Address - Street 1:305 S HWY 69
Practice Address - Street 2:
Practice Address - City:HUXLEY
Practice Address - State:IA
Practice Address - Zip Code:50124-8095
Practice Address - Country:US
Practice Address - Phone:515-597-2600
Practice Address - Fax:515-597-3945
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA30674207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1255391983Medicaid
IA151100Medicaid
IA151100Medicaid
IA1255391983Medicaid
IAF87180Medicare UPIN