Active NPI
Kenneth D Petersen, M.D.
- Obstetrics & Gynecology Physician
- Goshen, IN
National Provider Identifier
1922092733
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Obstetrics & Gynecology Physician
- License
- 01028273
- Practice address
- 1111 Lighthouse Lane
Goshen, IN 46526-3824 - Phone
- (574) 533-0348
- Fax
- (574) 533-0277
- NPI assigned
- Sep 7, 2005
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Obstetrics & Gynecology Physician | 207V00000X | 01028273 | IN | Primary |
Addresses
Primary practice location
1111 Lighthouse Lane
Goshen, IN 46526-3824
Mailing address
1111 Lighthouse Lane
Goshen, IN 46526-3824
Phone (574) 533-0348
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 01028273 | IN | MD | Obstetrics & Gynecology Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1126051200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1202083200000",
"number": "1922092733",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1111 LIGHTHOUSE LANE",
"city": "GOSHEN",
"state": "IN",
"postal_code": "465263824",
"telephone_number": "574-533-0348",
"fax_number": "574-533-0277"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1111 LIGHTHOUSE LANE",
"city": "GOSHEN",
"state": "IN",
"postal_code": "465263824",
"telephone_number": "574-533-0348",
"fax_number": "574-533-0277"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PETERSEN",
"first_name": "KENNETH",
"middle_name": "D",
"credential": "M.D.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2005-09-07",
"last_updated": "2008-02-04",
"status": "A"
},
"taxonomies": [
{
"code": "207V00000X",
"taxonomy_group": "",
"desc": "Obstetrics & Gynecology",
"state": "IN",
"license": "01028273",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Goshen, IN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 4, 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.