Basic Information
| Provider Information | |||||||||
| NPI: | 1508858861 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | KENNETH | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2627 RIVERSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322044712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043087372 | ||||||||
| FaxNumber: | 9043082998 | ||||||||
| Practice Location | |||||||||
| Address1: | 2627 RIVERSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322044712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043087372 | ||||||||
| FaxNumber: | 9043082998 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2005 | ||||||||
| LastUpdateDate: | 11/11/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| ParentOrganizationLBN: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME0067446 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5562171-001 | 01 | FL | CIGNA | OTHER | 26755 | 01 | FL | BCBS | OTHER | 379680900 | 05 | FL | MEDICAID | 4653879 | 01 | FL | AETNA | OTHER | 148899 | 01 | FL | HEALTHEASE | OTHER | 080119192 | 01 | FL | MEDICARE RAILROAD | OTHER |