1679926711 NPI number — KARSTEN PETERSON

Table of content: DR. WILLIAM KENT BROKKEN M.D. (NPI 1336140284)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679926711 NPI number — KARSTEN PETERSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
KARSTEN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1679926711
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/18/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
931 CHEVY WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEDFORD
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97504-4127
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-535-6239
Provider Business Mailing Address Fax Number:
541-512-1026

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1955 SCENIC AVE
Provider Second Line Business Practice Location Address:
CENTRAL POINT
Provider Business Practice Location Address City Name:
CENTRAL POINT
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97502-1652
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-494-6417
Provider Business Practice Location Address Fax Number:
541-494-6424
Provider Enumeration Date:
07/13/2016

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: 1041C0700X , with the licence number:  L10572 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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