Provider Demographics
NPI:1629150495
Name:PETER, CHARLTON A (DPM)
Entity Type:Individual
Prefix:
First Name:CHARLTON
Middle Name:A
Last Name:PETER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1254 NASHVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:TN
Mailing Address - Zip Code:37091-2222
Mailing Address - Country:US
Mailing Address - Phone:931-359-7677
Mailing Address - Fax:931-359-7784
Practice Address - Street 1:1254 NASHVILLE HWY
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:TN
Practice Address - Zip Code:37091-2222
Practice Address - Country:US
Practice Address - Phone:931-359-7677
Practice Address - Fax:931-359-7784
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDPM303213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3351297Medicaid
TN66264OtherBLUE CROSS BLUE SHIELD
0490250001OtherNSC PALMETTO GBA REG C
3351297Medicare ID - Type Unspecified
TN3351297Medicaid