Provider Demographics
NPI:1881905370
Name:PETERSON, GRANT E (MD)
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:E
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2515 SW STATE ST
Mailing Address - Street 2:STE 100
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50023-7079
Mailing Address - Country:US
Mailing Address - Phone:515-964-6929
Mailing Address - Fax:
Practice Address - Street 1:2515 SW STATE ST
Practice Address - Street 2:STE 100
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023-7079
Practice Address - Country:US
Practice Address - Phone:515-964-6929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-29
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE6336207R00000X
IAMD-41575207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1881905370Medicaid
IAP01353680OtherRR MEDICARE
IA1881905370Medicaid