Dale Edmund Petersen Jr., CP

Primary specialty

ProsthetistTaxonomy code 224P00000X

License

PRO66 Issued in FL

Practice address

4299 3Rd Ave
Marianna, FL 32446-2136

Phone

(850) 526-0063

Fax

(850) 526-1317

NPI assigned

Jun 11, 2007

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Vital Prosthetics, Inc.

  • Prosthetic/Orthotic Supplier
  • Marianna, FL
  • NPI 1114189669
  NPD (past) Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1181520000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1206662400000",
    "number": "1184827693",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 430",
            "city": "MARIANNA",
            "state": "FL",
            "postal_code": "324470430",
            "telephone_number": "850-526-0063"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4299 3RD AVE",
            "city": "MARIANNA",
            "state": "FL",
            "postal_code": "324462136",
            "telephone_number": "850-526-0063",
            "fax_number": "850-526-1317"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PETERSEN",
        "first_name": "DALE",
        "middle_name": "EDMUND",
        "name_suffix": "Jr.",
        "credential": "CP",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2007-06-11",
        "last_updated": "2008-03-28",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "224P00000X",
            "taxonomy_group": "",
            "desc": "Prosthetist",
            "state": "FL",
            "license": "PRO66",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Pelt Eye Clinic, P.a.
• Alan E Pelt, OD
• Ashley Pelt, DPT
• David G Pelt, OD
• Meagan Peluso, PT
• Tanya E Pierce, PTA
• Carrie Poole
• Geoffrey Brannon Poole
• Hope Bridwell Poole, NP
• Harry E Porter, LHMC

• Prosthetist in Marianna, FL
• Providers in Marianna, FL by specialty
• Prosthetist in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 28, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.