Provider Demographics
NPI:1447456272
Name:PETERSON, BARRY JOHN (DO)
Entity type:Individual
Prefix:DR
First Name:BARRY
Middle Name:JOHN
Last Name:PETERSON
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 1:256 N 2ND E
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-1638
Mailing Address - Country:US
Mailing Address - Phone:208-656-9646
Mailing Address - Fax:208-656-9645
Practice Address - Street 1:256 N 2ND E
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-1638
Practice Address - Country:US
Practice Address - Phone:208-656-9646
Practice Address - Fax:208-656-9645
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-0522207YX0905X, 207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy