Healthcare Provider Details

I. General information

NPI: 1154404226
Provider Name (Legal Business Name): JOHN M PETERSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72 BARRE ST
MONTPELIER VT
05602-3508
US

IV. Provider business mailing address

72 BARRE ST
MONTPELIER VT
05602-3508
US

V. Phone/Fax

Practice location:
  • Phone: 802-229-9418
  • Fax: 802-229-5619
Mailing address:
  • Phone: 802-229-9418
  • Fax: 802-229-5619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number032-0000291
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: