Basic Information
| Provider Information | |||||||||
| NPI: | 1023239753 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | DALE | ||||||||
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| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 356 | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672010356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8444689498 | ||||||||
| FaxNumber: | 8556301302 | ||||||||
| Practice Location | |||||||||
| Address1: | 929 N SAINT FRANCIS ST | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672143821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003745326 | ||||||||
| FaxNumber: | 8003747656 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2007 | ||||||||
| LastUpdateDate: | 10/31/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 0531672 | KS | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LC0200X | 0531672 | KS | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200611100A | 05 | KS | MEDICAID | P00727380 | 01 | KS | RR MEDICARE GROUP CQ2302 | OTHER | 200611100B | 05 | KS | MEDICAID |