Healthcare Provider Details

I. General information

NPI: 1396206397
Provider Name (Legal Business Name): MATTHEW PETERSEN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2019
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 SW ARCHER RD STE 4102
GAINESVILLE FL
32608-1135
US

IV. Provider business mailing address

1941 JOHNSON AVE STE 101
SAN LUIS OBISPO CA
93401-4154
US

V. Phone/Fax

Practice location:
  • Phone: 352-352-1611
  • Fax: 352-265-1107
Mailing address:
  • Phone: 805-872-8844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number20A24105
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number18980
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: