Provider Demographics
NPI:1538149042
Name:PETERSEN, ERIC SCOTT (DO)
Entity type:Individual
Prefix:MR
First Name:ERIC
Middle Name:SCOTT
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 W PLATT ST # 1
Mailing Address - Street 2:
Mailing Address - City:MAQUOKETA
Mailing Address - State:IA
Mailing Address - Zip Code:52060-2038
Mailing Address - Country:US
Mailing Address - Phone:563-652-5145
Mailing Address - Fax:563-652-3674
Practice Address - Street 1:918 W PLATT ST # 1
Practice Address - Street 2:
Practice Address - City:MAQUOKETA
Practice Address - State:IA
Practice Address - Zip Code:52060-2038
Practice Address - Country:US
Practice Address - Phone:563-652-5145
Practice Address - Fax:563-652-3674
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03059207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA4210571962002OtherJOHN DEERE HEALTHCARE
IA03059OtherIOWA LICENSE
IA080120570OtherRAILROAD MEDICARE
IA2147512Medicaid
IA1147512Medicaid
IA44479OtherWELLMARK BLUE CROSS
IA44479OtherWELLMARK BLUE CROSS
IA1147512Medicaid