Healthcare Provider Details

I. General information

NPI: 1093150260
Provider Name (Legal Business Name): JONATHAN CLARK PETERS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2013
Last Update Date: 06/02/2021
Certification Date: 06/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 PLEASANT ST
CONCORD NH
03301-2598
US

IV. Provider business mailing address

250 PLEASANT ST. MEDICAL STAFF SERVICES OFFICE
CONCORD NH
03301-7559
US

V. Phone/Fax

Practice location:
  • Phone: 603-228-7200
  • Fax: 603-227-7562
Mailing address:
  • Phone: 603-227-7000
  • Fax: 603-228-3307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO2872
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20988
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: