Provider Demographics
NPI:1801894860
Name:PETTERSON, KURT (DPM)
Entity type:Individual
Prefix:DR
First Name:KURT
Middle Name:
Last Name:PETTERSON
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 1:533 BROOKDALE DR
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28677-4107
Mailing Address - Country:US
Mailing Address - Phone:704-872-2028
Mailing Address - Fax:704-872-3390
Practice Address - Street 1:533 BROOKDALE DR
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-4107
Practice Address - Country:US
Practice Address - Phone:704-872-2028
Practice Address - Fax:704-872-3390
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC134213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8908136Medicaid
NCT64029Medicare UPIN
NC8908136Medicaid
NC0637430001Medicare NSC