Provider Demographics
NPI:1215001672
Name:PETERSON, CECIL BROADY (MD)
Entity Type:Individual
Prefix:DR
First Name:CECIL
Middle Name:BROADY
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 1:295 GREENWICH ST
Mailing Address - Street 2:APT # 3G
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10007-1049
Mailing Address - Country:US
Mailing Address - Phone:516-456-1403
Mailing Address - Fax:
Practice Address - Street 1:295 GREENWICH AVE
Practice Address - Street 2:APT #3G
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10007
Practice Address - Country:US
Practice Address - Phone:516-456-1403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY199078207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine