Provider Demographics
NPI:1295728236
Name:PETERSON, JOHN E (DO)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:E
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:104 N 7 HIGHWAY
Mailing Address - Street 2:SUITE B
Mailing Address - City:BLUE SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64014
Mailing Address - Country:US
Mailing Address - Phone:816-229-8880
Mailing Address - Fax:816-229-4363
Practice Address - Street 1:104 N 7 HIGHWAY
Practice Address - Street 2:SUITE B
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64014
Practice Address - Country:US
Practice Address - Phone:816-229-8880
Practice Address - Fax:816-229-4363
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2011-12-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MODO36953207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO15256101OtherBC/BS
MO2024981OtherAETNA
MOE11414Medicare UPIN
MO2024981OtherAETNA