Provider Demographics
NPI:1295800043
Name:PETERSON, THOMAS R (MD)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:R
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:140 PROSPECT AVE
Mailing Address - Street 2:SUITE 18
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601
Mailing Address - Country:US
Mailing Address - Phone:201-525-0500
Mailing Address - Fax:201-525-1171
Practice Address - Street 1:140 PROSPECT AVE
Practice Address - Street 2:SUITE 18
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601
Practice Address - Country:US
Practice Address - Phone:201-525-0500
Practice Address - Fax:201-525-1171
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJMA5194207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0154105Medicaid
NJPE581753Medicare ID - Type Unspecified
NJ0154105Medicaid