Basic Information
| Provider Information | |||||||||
| NPI: | 1326013426 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 814 PIERCE ST | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | SIOUX CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 511011058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122262600 | ||||||||
| FaxNumber: | 7122262605 | ||||||||
| Practice Location | |||||||||
| Address1: | 2600 OUTER DR N | ||||||||
| Address2: | |||||||||
| City: | SIOUX CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 511041585 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122393300 | ||||||||
| FaxNumber: | 7122398201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2006 | ||||||||
| LastUpdateDate: | 01/31/2011 | ||||||||
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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 | 207Q00000X | 03181 | IA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 75305796314 | 05 | NE | MEDICAID | 4186098 | 05 | IA | MEDICAID | 7786682 | 05 | SD | MEDICAID |