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NPI Code Detail

MEDICARE: DR. JACOB EDWARD PETERSON MD, MBA

MEDICARE: DR. JACOB EDWARD PETERSON MD, MBA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1390200000XStudent in an Organized Health Care Education/Training Program
2207R00000XInternal Medicine Physician76208CT
3207R00000XInternal Medicine Physician0101263068VA
4208M00000XHospitalist Physician0101263068VA
5208D00000XGeneral Practice Physician0101263068VA
6207RP1001XPulmonary Disease Physician76208CT

General Provider Information

NPI Number : 1295196384
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. JACOB EDWARD PETERSON MD, MBA
Provider Business Mailing Address
First Line : 20 YORK ST
Second Line :
City : NEW HAVEN
State : CT
Zip : 06510-3220
Country : US
Telephone Number : 203-688-4242
Fax Number :
Provider Business Practice Location Address
First Line : 79 WAWECUS ST STE 103
Second Line :
City : NORWICH
State : CT
Zip : 06360-2173
Country : US
Telephone Number : 860-886-1862
Fax Number : 860-886-2046
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/16/2016
Last Update Date : 02/12/2026

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