Basic Information
Provider Information
NPI: 1033558010
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: PETERSON
FirstName: JUSTIN
MiddleName: WILLIAM
NamePrefix: DR.
NameSuffix:  
Credential: D.O.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 10352 EDGEWATER TRL
Address2:  
City: HOLLY
State: MI
PostalCode: 484429337
CountryCode: US
TelephoneNumber: 2316492036
FaxNumber:  
Practice Location
Address1: 1 GENESYS PKWY
Address2:  
City: GRAND BLANC
State: MI
PostalCode: 484398065
CountryCode: US
TelephoneNumber: 8106065000
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/23/2013
LastUpdateDate: 06/23/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207X00000X5101020737MIY Allopathic & Osteopathic PhysiciansOrthopaedic Surgery 

No ID Information.


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