Healthcare Provider Details

I. General information

NPI: 1295196384
Provider Name (Legal Business Name): JACOB EDWARD PETERSON MD, MBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JACOB EDWARD PETERSON MD, MBA

II. Dates (important events)

Enumeration Date: 03/16/2016
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 WAWECUS ST STE 103
NORWICH CT
06360-2173
US

IV. Provider business mailing address

79 WAWECUS ST STE 103
NORWICH CT
06360-2173
US

V. Phone/Fax

Practice location:
  • Phone: 860-886-1862
  • Fax: 860-886-2046
Mailing address:
  • Phone: 860-886-1862
  • Fax: 860-886-2046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0101263068
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number0101263068
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number76208
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101263068
License Number StateVA
# 5
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number76208
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: