Healthcare Provider Details

I. General information

NPI: 1790032530
Provider Name (Legal Business Name): KYLE PETERSEN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2012
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 WESTON RD STE 101
WESTON FL
33326-1112
US

IV. Provider business mailing address

55 WESTON RD STE 101
WESTON FL
33326-1112
US

V. Phone/Fax

Practice location:
  • Phone: 954-280-2230
  • Fax: 954-960-6355
Mailing address:
  • Phone: 954-280-2230
  • Fax: 954-960-6355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS11815
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: