Provider Demographics
NPI:1366477200
Name:PETERSON, ERIC BRUCE (MS, FAAA)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:BRUCE
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MS, FAAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15307 SPRING MIST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247-5708
Mailing Address - Country:US
Mailing Address - Phone:210-967-5857
Mailing Address - Fax:
Practice Address - Street 1:5788 ECKHERT RD
Practice Address - Street 2:VA OUTPATIENT CLINIC (ATTN: AUDIOLOGY)
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240
Practice Address - Country:US
Practice Address - Phone:210-699-2100
Practice Address - Fax:210-699-2260
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX51123231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist