Healthcare Provider Details

I. General information

NPI: 1558999524
Provider Name (Legal Business Name): JOHN DAVID PETERSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2020
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 FISHER ST
BILOXI MS
39534-2508
US

IV. Provider business mailing address

301 FISHER ST
BILOXI MS
39534-2508
US

V. Phone/Fax

Practice location:
  • Phone: 228-376-0425
  • Fax:
Mailing address:
  • Phone: 228-376-0425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number83119
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: