Provider Demographics
NPI:1801884184
Name:PETERSON, ALLAN E (MD)
Entity type:Individual
Prefix:
First Name:ALLAN
Middle Name:E
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1229 C AVE E
Mailing Address - Street 2:
Mailing Address - City:OSKALOOSA
Mailing Address - State:IA
Mailing Address - Zip Code:52577-4246
Mailing Address - Country:US
Mailing Address - Phone:641-672-3360
Mailing Address - Fax:641-672-3366
Practice Address - Street 1:410 N 12TH ST
Practice Address - Street 2:
Practice Address - City:OSKALOOSA
Practice Address - State:IA
Practice Address - Zip Code:52577-2495
Practice Address - Country:US
Practice Address - Phone:641-672-3360
Practice Address - Fax:641-672-2258
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA19419207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA19419OtherLICENSE
IAA01041Medicare UPIN