Provider Demographics
NPI:1932201985
Name:PETERSON, RICHARD BOYD (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:BOYD
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 DIVISION ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1400
Mailing Address - Country:US
Mailing Address - Phone:304-766-4342
Mailing Address - Fax:304-766-3541
Practice Address - Street 1:424 DIVISION ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1400
Practice Address - Country:US
Practice Address - Phone:304-766-4342
Practice Address - Fax:304-766-3541
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19060207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0088429000Medicaid
WV0088429000Medicaid
WVPE0831543Medicare ID - Type Unspecified