Healthcare Provider Details

I. General information

NPI: 1528024072
Provider Name (Legal Business Name): W JOSEPH PETERSON DOM, AP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12100 COBBLESTONE DR STE 3
BAYONET POINT FL
34667-2487
US

IV. Provider business mailing address

12100 COBBLESTONE DR STE 3
BAYONET POINT FL
34667-2487
US

V. Phone/Fax

Practice location:
  • Phone: 727-378-7469
  • Fax:
Mailing address:
  • Phone: 727-378-7469
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAP-1568
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: