Provider Demographics
NPI:1306849500
Name:PETERSON, STEVE LEROY (MD)
Entity Type:Individual
Prefix:
First Name:STEVE
Middle Name:LEROY
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 1:1009 NORTH STATE OF FRANKLIN ACCESS ROAD
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604
Mailing Address - Country:US
Mailing Address - Phone:423-929-7546
Mailing Address - Fax:423-929-7968
Practice Address - Street 1:1009 NORTH STATE OF FRANKLIN ACCESS ROAD
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604
Practice Address - Country:US
Practice Address - Phone:423-929-7546
Practice Address - Fax:423-929-7968
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN39354207YX0905X, 207YX0007X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
No207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery