Provider Demographics
NPI:1801896766
Name:JOHN L PETERSON MD
Entity type:Organization
Organization Name:JOHN L PETERSON MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:FAIRCLOTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-775-8183
Mailing Address - Street 1:1013 CARTHAGE ST
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27330-4114
Mailing Address - Country:US
Mailing Address - Phone:919-775-8183
Mailing Address - Fax:919-775-8152
Practice Address - Street 1:1013 CARTHAGE ST
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-4114
Practice Address - Country:US
Practice Address - Phone:919-775-8183
Practice Address - Fax:919-775-8152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-21
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC38166207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890230FMedicaid
NC2317975Medicare ID - Type Unspecified
NC890230FMedicaid
NC1024260001Medicare NSC