Provider Demographics
NPI:1750363149
Name:PETERSEN, DAVID A (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:A
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 1:1433 S FORT HARRISON AVE STE D
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33756-2072
Mailing Address - Country:US
Mailing Address - Phone:727-724-3985
Mailing Address - Fax:727-726-7553
Practice Address - Street 1:1095 N MAIN ST STE L
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92867-5459
Practice Address - Country:US
Practice Address - Phone:844-484-4267
Practice Address - Fax:949-381-5687
Is Sole Proprietor?:No
Enumeration Date:2005-11-19
Last Update Date:2023-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME54499207X00000X
CAG130506207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL037919100Medicaid
FLE21434Medicare UPIN
FL037919100Medicaid
FL07876YMedicare ID - Type Unspecified