Provider Demographics
NPI:1114151230
Name:PETERSON, CARL ROY III (MD, MS)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:ROY
Last Name:PETERSON
Suffix:III
Gender:M
Credentials:MD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8401 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-6725
Mailing Address - Country:US
Mailing Address - Phone:330-629-7500
Mailing Address - Fax:330-629-7503
Practice Address - Street 1:8401 MARKET ST
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-6725
Practice Address - Country:US
Practice Address - Phone:330-629-7500
Practice Address - Fax:330-629-7504
Is Sole Proprietor?:No
Enumeration Date:2009-05-04
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.1238502085R0001X
OH35.0914962085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0107099Medicaid