Healthcare Provider Details

I. General information

NPI: 1528036142
Provider Name (Legal Business Name): RENE A PETERSON DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 03/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35202 ATLANTIC AVE
MILLVILLE DE
19967
US

IV. Provider business mailing address

35202 ATLANTIC AVE
MILLVILLE DE
19967-6901
US

V. Phone/Fax

Practice location:
  • Phone: 302-541-0323
  • Fax: 302-539-8736
Mailing address:
  • Phone: 302-541-0323
  • Fax: 302-539-8736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberE10000129
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: