Healthcare Provider Details

I. General information

NPI: 1316212517
Provider Name (Legal Business Name): ANDREW HUNTER PETERSEN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2012
Last Update Date: 09/17/2020
Certification Date: 09/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 W MAPLE AVE
FAYETTEVILLE WV
25840-1445
US

IV. Provider business mailing address

5378 AVERY RD
DUBLIN OH
43016-6933
US

V. Phone/Fax

Practice location:
  • Phone: 304-900-5511
  • Fax:
Mailing address:
  • Phone: 614-771-9871
  • Fax: 614-771-9877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number207YX0905X
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: