Healthcare Provider Details

I. General information

NPI: 1134481831
Provider Name (Legal Business Name): JOHANNA SUZANNE PETERSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2012
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 RAINBOW BLVD. 6040 DELP, MS1020 DIVISION OF GENERAL AND GERIATRIC MEDICINE, UNIVERSITY
KANSAS CITY KS
66160-0001
US

IV. Provider business mailing address

3901 RAINBOW BLVD. 4070 DELP, MS 4017 KANSSAS UNIVERSITY PHYSICIANS, INC.
KANSAS CITY KS
66160-0001
US

V. Phone/Fax

Practice location:
  • Phone: 913-588-6005
  • Fax: 913-588-3877
Mailing address:
  • Phone: 913-588-2501
  • Fax: 913-588-0593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number9407884
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: