=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376938902
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSIAH PETERSEN M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2015
-----------------------------------------------------
Last Update Date | 03/19/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 HEALTHY WAY
-----------------------------------------------------
City | OCEANSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11572-1551
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-632-3000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 HEALTHY WAY
-----------------------------------------------------
City | OCEANSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11572-1551
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | ML 60561474
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 294319
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------