Provider Demographics
NPI:1659395523
Name:PETERSON, WYLAN CORNELIUS (MD)
Entity Type:Individual
Prefix:DR
First Name:WYLAN
Middle Name:CORNELIUS
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 1:3551 ROGER BROOKE DR
Mailing Address - Street 2:ATT'N MS. SHAWANA JUDGE
Mailing Address - City:FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-4504
Mailing Address - Country:US
Mailing Address - Phone:210-916-1064
Mailing Address - Fax:
Practice Address - Street 1:3551 ROGER BROOKE DR
Practice Address - Street 2:ATT'N MS. SHAWANA JUDGE
Practice Address - City:FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4504
Practice Address - Country:US
Practice Address - Phone:210-916-1064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ01512086S0102X, 208600000X, 207RC0200X
OH35-08-5446208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHI26627Medicare UPIN
OHPE4153894Medicare ID - Type UnspecifiedKETTERING MEDICARE #
OHPE4153893Medicare ID - Type UnspecifiedMIDDLETOWN MEDICARE #
OHPE4153891Medicare ID - Type UnspecifiedSPRINGDALE MEDICARE #
OHPE4153895Medicare ID - Type UnspecifiedDAYTON MEDICARE #
OHPE4153892Medicare ID - Type UnspecifiedMILFORD MEDICARE #
OHPE4153897Medicare ID - Type UnspecifiedFAIRBORN MEDICARE #
OHPE4153896Medicare ID - Type UnspecifiedCOLERAIN MEDICARE #