Provider Demographics
NPI:1750370425
Name:PETERS, PAUL LEROY (DC)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:LEROY
Last Name:PETERS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2378 S AVE
Mailing Address - Street 2:
Mailing Address - City:MADRID
Mailing Address - State:IA
Mailing Address - Zip Code:50156-7593
Mailing Address - Country:US
Mailing Address - Phone:515-795-3655
Mailing Address - Fax:515-795-3656
Practice Address - Street 1:2378 S AVE
Practice Address - Street 2:
Practice Address - City:MADRID
Practice Address - State:IA
Practice Address - Zip Code:50156-7593
Practice Address - Country:US
Practice Address - Phone:515-795-3655
Practice Address - Fax:515-795-3656
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-17
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA05497111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0431379Medicaid
IA2102442Medicaid
18766OtherBLUE CROSS
18766OtherBLUE CROSS
T92982Medicare UPIN
I12150Medicare ID - Type UnspecifiedGROUP