Mack Andelin Peterson, D.O.

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

License

1535 Issued in NE

Practice address

1100 Wilford Hall Loop BLDG 4554
Jbsa Lackland, TX 78236-5638

Phone

(315) 630-4060

NPI assigned

Jun 16, 2014

Last updated

Jul 8, 2024By the provider in NPPES

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)

Enrolled

Credentials

Doctor of Osteopathy

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

{
    "created_epoch": "1402876800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1720396800000",
    "number": "1396159521",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1100 WILFORD HALL LOOP BLDG 4554",
            "city": "JBSA LACKLAND",
            "state": "TX",
            "postal_code": "782365638"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1100 WILFORD HALL LOOP BLDG 4554",
            "city": "JBSA LACKLAND",
            "state": "TX",
            "postal_code": "782365638",
            "telephone_number": "315-630-4060"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PETERSON",
        "first_name": "MACK",
        "middle_name": "ANDELIN",
        "name_prefix": "Dr.",
        "credential": "D.O.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2014-06-16",
        "last_updated": "2024-07-08",
        "certification_date": "2024-07-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NE",
            "license": "1535",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Eric R Parsons, PHARM. D.
• Martha Ellan Paul, CRNA
• Mary T Pawlak, MD
• Shannel Anyae Pegram, DO
• Daniel Alexander Perales, PHYSICIAN ASSISTANT
• Kyle Petrey, DPT
• Jamila Lee Petterson, PAC
• Emily Grace Philips, OTD, OTR/L
• James Richard Phillips, DPT
• Assia L Phoenix, APRN, FNP-C

• Family Medicine Physician in Jbsa Lackland, TX
• Providers in Jbsa Lackland, TX by specialty
• Family Medicine Physician in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2024; 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.