Individual
DR. JACK T PETERSON JR.
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
631 SW HORNE ST, STE 400, TOPEKA, KS 66606-1661
(785) 234-9000
(785) 234-9119
Mailing address
631 SW HORNE ST, STE 400, TOPEKA, KS 66606-1661
(785) 234-9000
(785) 234-9119
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
0422259
KS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100144860B
—
KS
01
—
100516
BLUE CROSS
KS
01
—
240007246
RAILROAD MEDICARE
KS
01
—
481191346
TAX ID
KS
01
—
628770
FIRST GUARD
KS
Enumeration date
06/09/2005
Last updated
04/24/2012
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