| Doctor Name: | DR. KYLE PETERSEN |
| NPI Number: | 1790032530 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | D.O. |
| License Number: | OS 11815 |
| Business Practice Address: | 1400 S Andrews Ave Fort Lauderdale, FL - 333161840 |
| Business Phone Number: | 9547648911 |
| Business Fax Number: | |
| Mailing Address: | 8930 W State Road 84, 210 DAVIE |
| State: | FL |
| Postal Code: | 333244456 |
| Phone Number: | 9547648911 |
| Fax Number: | |
| NPI Enumeration Date: | 08/10/2012 |
| NPI Last Update Date: | 10/17/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 208D00000X |
| License Number: | OS 11815 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | FL |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | General Practice |
| Taxonomy Specialization: | |
| Taxonomy Definition: | |