Provider Demographics
NPI:1902883846
Name:PETERSON, DANIEL J (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:J
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:345 E MOUNT AIRY AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19119-1114
Mailing Address - Country:US
Mailing Address - Phone:215-242-5000
Mailing Address - Fax:215-242-5086
Practice Address - Street 1:345 E MOUNT AIRY AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19119-1114
Practice Address - Country:US
Practice Address - Phone:215-242-5000
Practice Address - Fax:215-242-5086
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2016-03-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PAPAMD430498207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101958464Medicaid
PAH69339Medicare UPIN
NYH69339Medicare UPIN