Basic Information
| Provider Information | |||||||||
| NPI: | 1033558010 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10352 EDGEWATER TRL | ||||||||
| Address2: | |||||||||
| City: | HOLLY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484429337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2316492036 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 GENESYS PKWY | ||||||||
| Address2: | |||||||||
| City: | GRAND BLANC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484398065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8106065000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2013 | ||||||||
| LastUpdateDate: | 06/23/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 5101020737 | MI | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.