Healthcare Provider Details

I. General information

NPI: 1780985234
Provider Name (Legal Business Name): JOHN DAVID PETERSON DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2010
Last Update Date: 07/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8300 CARMEL AVE NE #501
ALBUQUERQUE NM
87122-3147
US

IV. Provider business mailing address

3821 MOUNT RAINIER DR NE
ALBUQUERQUE NM
87111-4356
US

V. Phone/Fax

Practice location:
  • Phone: 505-797-1001
  • Fax:
Mailing address:
  • Phone: 276-644-6880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number59.000337
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: