Provider Demographics
NPI:1780897033
Name:PETERS, JUANDALYN ROZELDA (MD)
Entity type:Individual
Prefix:
First Name:JUANDALYN
Middle Name:ROZELDA
Last Name:PETERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4801 S UNIVERSITY DR
Mailing Address - Street 2:SUITE 204
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-3839
Mailing Address - Country:US
Mailing Address - Phone:786-255-0347
Mailing Address - Fax:954-206-4554
Practice Address - Street 1:4801 S UNIVERSITY DR
Practice Address - Street 2:SUITE 204
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-3839
Practice Address - Country:US
Practice Address - Phone:786-255-0347
Practice Address - Fax:954-206-4554
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME851302084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL272029900Medicaid