Individual
DR. JOSEPH R PETERSEN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
1344 HILAND AVE STE A, BURLEY, ID 83318-1564
(208) 678-1138
(208) 678-5833
Mailing address
1344 HILAND AVE STE A, P. O. BOX 1263, BURLEY, ID 83318-1564
(208) 678-1138
(208) 678-5833
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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