MEDICARE: DR. KYLE PETERSEN D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	OS11815	FL

General Provider Information

NPI Number	:	1790032530
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KYLE PETERSEN D.O.

Provider Business Mailing Address
First Line	:	3157 N UNIVERSITY DR STE 101
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33024-2258
Country	:	US
Telephone Number	:	754-206-8250
Fax Number	:	754-206-8260

Provider Business Practice Location Address
First Line	:	3157 N UNIVERSITY DR STE 101
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33024-2258
Country	:	US
Telephone Number	:	754-206-8250
Fax Number	:	754-206-8260

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/10/2012
Last Update Date	:	01/23/2020

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