# DR. JOSEPH R PETERSEN

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- **Entity:** Individual
- **Status:** Active
- **Sole proprietor:** Yes

## Provider details

- **NPI number:** 1225105604
- **Gender:** Man

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 174400000X | Specialist | M5283 | ID | Yes |

## Other

- **Enumeration date:** 11/29/2006
- **Last updated:** 07/09/2007

## 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 |