Provider Demographics
NPI:1013397462
Name:PETERSON, MATTHEW CHRISTOPHER (LAC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:CHRISTOPHER
Last Name:PETERSON
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 E MAIN ST
Mailing Address - Street 2:SUITE 111
Mailing Address - City:NEW ALBANY
Mailing Address - State:OH
Mailing Address - Zip Code:43054-9466
Mailing Address - Country:US
Mailing Address - Phone:614-933-0700
Mailing Address - Fax:
Practice Address - Street 1:39 E MAIN ST
Practice Address - Street 2:SUITE 111
Practice Address - City:NEW ALBANY
Practice Address - State:OH
Practice Address - Zip Code:43054-9466
Practice Address - Country:US
Practice Address - Phone:614-933-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-01
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH65.000280171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist