Provider Demographics
NPI:1912056052
Name:PETERS, JEROME (DO)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:
Last Name:PETERS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5300 ARSENAL ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63139-1463
Mailing Address - Country:US
Mailing Address - Phone:314-877-5781
Mailing Address - Fax:314-877-6106
Practice Address - Street 1:5300 ARSENAL ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63139-1463
Practice Address - Country:US
Practice Address - Phone:314-877-5781
Practice Address - Fax:314-877-6106
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR7A462084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO241518240Medicaid
MO241518240Medicaid
MO328680162Medicare PIN