1598268526 NPI number — DR. PETA-GAYE KENISHA PETERSON DO

Table of content: DR. PETA-GAYE KENISHA PETERSON DO (NPI 1598268526)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598268526 NPI number — DR. PETA-GAYE KENISHA PETERSON DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
PETA-GAYE
Provider Middle Name:
KENISHA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1598268526
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/27/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
379 CAMPUS DR FL 4
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOMERSET
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08873-1161
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-937-8939
Provider Business Mailing Address Fax Number:
732-418-8372

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
166 LYONS AVE FL 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07112-2016
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-926-7282
Provider Business Practice Location Address Fax Number:
973-923-2978
Provider Enumeration Date:
03/15/2018

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: 208000000X , with the licence number:  25MB10341500 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208000000X , with the licence number: 298839 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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