Provider Demographics
NPI:1639236995
Name:PETERSON, LARYN A (MD)
Entity Type:Individual
Prefix:
First Name:LARYN
Middle Name:A
Last Name:PETERSON
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 1:9002 N MERIDIAN ST STE 222
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-5350
Mailing Address - Country:US
Mailing Address - Phone:317-819-4516
Mailing Address - Fax:317-819-0044
Practice Address - Street 1:8040 CLEARVISTA PKWY STE 350
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-4673
Practice Address - Country:US
Practice Address - Phone:317-844-7059
Practice Address - Fax:317-819-0044
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01031101A207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN040014115OtherMEDICARE RAILROAD
IN100226860Medicaid
INP01157080OtherMEDICARE RR
INC25627Medicare UPIN
IN100226860Medicaid
IN040014115OtherMEDICARE RAILROAD
IN100226860Medicaid