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Individual
DR. JOSEPH R PETERSEN
Active
Individual
DR. JOSEPH R PETERSEN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
M5283
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010003563
BLUE SHIELD PROVIDER NO.
ID
01
—
014917
SELECTCARE
ID
01
—
0791870001
MEDICARE DMERC
ID
01
—
74096
BLUE CROSS PROVIDER NUMBE
ID
01
—
C36979
DMBA
ID
01
—
I000490
TRICARE
ID
Enumeration date
11/29/2006
Last updated
07/09/2007
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