Basic Information
| Provider Information | |||||||||
| NPI: | 1255437109 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSEN | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | LEWIS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5901 SW 74TH ST | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331435165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056654614 | ||||||||
| FaxNumber: | 3056670239 | ||||||||
| Practice Location | |||||||||
| Address1: | 3663 S MIAMI AVE | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331334253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056654614 | ||||||||
| FaxNumber: | 3056670239 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 08/08/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | ME82450 | FL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 262547400 | 05 | FL | MEDICAID | 03222 | 01 | FL | BCBS | OTHER |