Provider Demographics
NPI:1639330996
Name:PETERSON, BRIAN WADE (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:WADE
Last Name:PETERSON
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 1:3800 HOUMA BLVD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70006-4182
Mailing Address - Country:US
Mailing Address - Phone:504-885-7337
Mailing Address - Fax:
Practice Address - Street 1:3800 HOUMA BLVD
Practice Address - Street 2:SUITE 205
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006-4182
Practice Address - Country:US
Practice Address - Phone:504-885-7337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-19
Last Update Date:2013-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LAMD.2052292084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program