Healthcare Provider Details

I. General information

NPI: 1538149042
Provider Name (Legal Business Name): ERIC SCOTT PETERSEN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 03/07/2023
Certification Date: 05/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

918 W PLATT ST # 1
MAQUOKETA IA
52060-2038
US

IV. Provider business mailing address

918 W PLATT ST # 1
MAQUOKETA IA
52060-2038
US

V. Phone/Fax

Practice location:
  • Phone: 563-652-5145
  • Fax: 563-652-3674
Mailing address:
  • Phone: 563-652-5145
  • Fax: 563-652-3674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number03059
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: