Individual
MARY KAY PETERSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
3680 BROADWAY, FORT MYERS, FL 33901-8005
(239) 936-2316
Mailing address
3660 BROADWAY, FORT MYERS, FL 33901-8005
(239) 936-2316
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
ME77132
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2439859
AETNA HMO
—
05
—
257739900
—
FL
01
—
46568
BCBS
—
01
—
7405122
AETNA PPO
—
01
—
ME77132
FLORIDA LICENSE
FL
Enumeration date
06/05/2006
Last updated
05/29/2008
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