1598864282 NPI number — DR. NICKALOS LEE PETERSON D.C.

Table of content: DR. NICKALOS LEE PETERSON D.C. (NPI 1598864282)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598864282 NPI number — DR. NICKALOS LEE PETERSON D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
NICKALOS
Provider Middle Name:
LEE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C.
Provider Gender Code:
M

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:
1598864282
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
31 BAILEY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIDGEFIELD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06877-4533
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-438-9609
Provider Business Mailing Address Fax Number:
203-438-7141

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
31 BAILEY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIDGEFIELD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06877-4533
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-438-9609
Provider Business Practice Location Address Fax Number:
203-438-7141
Provider Enumeration Date:
09/21/2006

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: 111N00000X , with the licence number:  180 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P405105 . This is a "OXFORD PROVIDER ID NUMBER" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 4380815 . This is a "AETNA PPO ID NUMBER" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 050000180CT01 . This is a "ANTHEM BC/BS ID PROVIDER" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: LANDMARK /HEALTH NET . This is a "CT00180 PROVIDER ID#" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 9323280003 . This is a "CIGNA PROVIDER ID NUMBER" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 0114667 . This is a "AETNA HMO ID NUMBER" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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