Provider Demographics
NPI:1497250252
Name:PETERSON, ERIC LEE
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:LEE
Last Name:PETERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1789
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24008-1789
Mailing Address - Country:US
Mailing Address - Phone:540-855-5100
Mailing Address - Fax:540-387-3349
Practice Address - Street 1:426 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-3610
Practice Address - Country:US
Practice Address - Phone:540-855-5100
Practice Address - Fax:540-387-3349
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-26
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101275027207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1497250252Medicaid