Provider Demographics
NPI:1508874959
Name:ST PETERY, LOUIS (MD)
Entity Type:Individual
Prefix:DR
First Name:LOUIS
Middle Name:
Last Name:ST PETERY
Suffix:
Gender:M
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:PO BOX 12427
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32317-2427
Mailing Address - Country:US
Mailing Address - Phone:850-297-0114
Mailing Address - Fax:850-297-2020
Practice Address - Street 1:1132 LEE AVE
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32303-6508
Practice Address - Country:US
Practice Address - Phone:850-224-8833
Practice Address - Fax:850-224-8802
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME173952080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00055118AMedicaid
FL537047001Medicaid
D50262Medicare UPIN