Individual
DR. JEFFREY E PETERSEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1011 BOWLES AVE, SUITE 121, FENTON, MO 63026-2395
(314) 200-2713
(314) 200-2714
Mailing address
1011 BOWLES AVE, SUITE 121, FENTON, MO 63026-2395
(314) 200-2713
(314) 200-2714
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
2001020599
MO
207ND0101X
MOHS-Micrographic Surgery Physician
2001020599
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
146422
MO-BLUE SHIELD
—
05
—
205401409
—
MO
01
—
3177332
CIGNA
MO
01
—
703212
AETNA
MO
01
—
853972
ANTHEM
MO
Enumeration date
07/17/2006
Last updated
07/25/2014
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