Provider Demographics
NPI:1508392366
Name:PETERSEN, ERIN (MD)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:
Last Name:PETERSEN
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 1:3631 BIENVILLE BLVD
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-5702
Mailing Address - Country:US
Mailing Address - Phone:228-875-2020
Mailing Address - Fax:228-875-2036
Practice Address - Street 1:3631 BIENVILLE BLVD
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-5702
Practice Address - Country:US
Practice Address - Phone:228-875-2020
Practice Address - Fax:228-875-2036
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-3405207W00000X
390200000X
MS27698207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program