Basic Information
| Provider Information | |||||||||
| NPI: | 1568460061 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | CRAIG | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3178 | ||||||||
| Address2: | |||||||||
| City: | CEDAR RAPIDS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 524063178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193981583 | ||||||||
| FaxNumber: | 3193992085 | ||||||||
| Practice Location | |||||||||
| Address1: | 202 10TH STREET SE | ||||||||
| Address2: | |||||||||
| City: | CEDAR RAPIDS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 524032404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193981721 | ||||||||
| FaxNumber: | 3193992016 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2005 | ||||||||
| LastUpdateDate: | 10/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 28341 | IA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 56483 | 01 | IA | BLUE CROSS/BLUE SHIELD | OTHER | 3075358 | 05 | IA | MEDICAID |