Provider Demographics
NPI:1356778419
Name:PETERSEN, KEVIN THOMAS (DO)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:THOMAS
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 1:220 HOVEY RD FL 32508
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32508-1044
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:220 HOVEY RD FL 32508
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32508-1044
Practice Address - Country:US
Practice Address - Phone:850-452-9484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-03
Last Update Date:2025-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVDO3578208600000X
NY294233208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery