Provider Demographics
NPI:1780985234
Name:PETERSON, JOHN DAVID (DPM)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:DAVID
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3821 MOUNT RAINIER DR NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-4356
Mailing Address - Country:US
Mailing Address - Phone:276-644-6880
Mailing Address - Fax:
Practice Address - Street 1:8300 CARMEL AVE NE
Practice Address - Street 2:#501
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87122-3147
Practice Address - Country:US
Practice Address - Phone:505-797-1001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-15
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH59.000337213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH59.000337OtherOHIO LISCENSE TRAINING CERTIFICATE