Provider Demographics
NPI:1437322633
Name:D.T. PETERSON, DPM, PC
Entity Type:Organization
Organization Name:D.T. PETERSON, DPM, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:516-496-0900
Mailing Address - Street 1:8029 JERICHO TPKE
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11797-1212
Mailing Address - Country:US
Mailing Address - Phone:516-496-0900
Mailing Address - Fax:516-496-0901
Practice Address - Street 1:8029 JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NY
Practice Address - Zip Code:11797-1212
Practice Address - Country:US
Practice Address - Phone:516-496-0900
Practice Address - Fax:516-496-0901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-08
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004585213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY4207430001Medicare NSC