Healthcare Provider Details

I. General information

NPI: 1669979514
Provider Name (Legal Business Name): KENT JOHN PETERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2018
Last Update Date: 01/28/2026
Certification Date: 01/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 BROADWAY N
FARGO ND
58102-3641
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 801-234-2000
  • Fax:
Mailing address:
  • Phone: 701-234-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number22778
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: