Provider Demographics
NPI:1336119866
Name:PETERSON, KERI L (MD)
Entity Type:Individual
Prefix:DR
First Name:KERI
Middle Name:L
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 E 57TH ST STE 510
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-2221
Mailing Address - Country:US
Mailing Address - Phone:212-583-2962
Mailing Address - Fax:212-744-4072
Practice Address - Street 1:115 E 57TH ST STE 510
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-2221
Practice Address - Country:US
Practice Address - Phone:212-583-2962
Practice Address - Fax:212-744-4072
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY207072207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY207072OtherLICENSE
NY02132305Medicaid
NYBP6473184OtherDEA#
NY02132305Medicaid
NYBP6473184OtherDEA#