Provider Demographics
NPI:1033146410
Name:PETERSON, ERIK (DO)
Entity Type:Individual
Prefix:
First Name:ERIK
Middle Name:
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 1:156 WEST AVE
Mailing Address - Street 2:EMERGENCY DEPARTMENT
Mailing Address - City:BROCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14420-1229
Mailing Address - Country:US
Mailing Address - Phone:585-395-6095
Mailing Address - Fax:585-395-6017
Practice Address - Street 1:156 WEST AVE
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:BROCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14420-1229
Practice Address - Country:US
Practice Address - Phone:585-395-6095
Practice Address - Fax:585-395-6017
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174771207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01477554Medicaid
NY174771-6WOtherWORKER'S COMPENSATION
NY70000A GRPMedicare PIN
NY174771-6WOtherWORKER'S COMPENSATION