Provider Demographics
NPI:1528552510
Name:PETERSON, LANCE WILLIAM (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:LANCE
Middle Name:WILLIAM
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD, PHD
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Other - First Name:
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Mailing Address - Street 1:1 CHILDREN'S PL CB 8116
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110
Mailing Address - Country:US
Mailing Address - Phone:314-454-6124
Mailing Address - Fax:314-454-4861
Practice Address - Street 1:1 CHILDRENS PL CB 8116
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1081
Practice Address - Country:US
Practice Address - Phone:314-454-6124
Practice Address - Fax:314-454-4861
Is Sole Proprietor?:No
Enumeration Date:2018-06-21
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2018018325208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics