Doctor Name: | DR. LARRY DEAN PETERSON |
NPI Number: | 1053441485 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | MD |
License Number: | |
Business Practice Address: | 209 19th St East Moline, IL - 61244 |
Business Phone Number: | 3097552944 |
Business Fax Number: | 3097559048 |
Mailing Address: | 2701 Blackhawk Rd, ROCK ISLAND |
State: | IL |
Postal Code: | 61201 |
Phone Number: | 3097881787 |
Fax Number: | |
NPI Enumeration Date: | 03/06/2007 |
NPI Last Update Date: | 07/08/2007 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 208D00000X |
License Number: | |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | IL |
Taxonomy Type: | Allopathic & Osteopathic Physicians |
Taxonomy Classification: | General Practice |
Taxonomy Specialization: | |
Taxonomy Definition: |