1023251840 NPI number — JUDY JONES PETERSEN D.O.

Table of content: JUDY JONES PETERSEN D.O. (NPI 1023251840)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023251840 NPI number — JUDY JONES PETERSEN D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSEN
Provider First Name:
JUDY
Provider Middle Name:
JONES
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023251840
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
415 MORRIS ST
Provider Second Line Business Mailing Address:
SUITE 304
Provider Business Mailing Address City Name:
CHARLESTON
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25301-1842
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-388-7782
Provider Business Mailing Address Fax Number:
304-388-7788

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 MORRIS ST
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25301-1409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-388-7040
Provider Business Practice Location Address Fax Number:
304-388-7041
Provider Enumeration Date:
04/08/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 1108 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P0106337 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 0041503000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".