Provider Demographics
NPI:1659698967
Name:PETERSON, LUKE TYLER (MD)
Entity Type:Individual
Prefix:DR
First Name:LUKE
Middle Name:TYLER
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 1:4101 CAMPUS RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-5077
Mailing Address - Country:US
Mailing Address - Phone:404-295-6810
Mailing Address - Fax:833-231-6851
Practice Address - Street 1:4101 CAMPUS RIDGE RD
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-5077
Practice Address - Country:US
Practice Address - Phone:404-295-6810
Practice Address - Fax:833-231-6851
Is Sole Proprietor?:No
Enumeration Date:2010-04-26
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN53018207W00000X
MS23966207W00000X, 207WX0009X
GA072079207W00000X
ARE-9417207W00000X
ARE9417207WX0009X
SCMD81655207WX0009X
NC2018-02590207WX0009X
NC20018-02590207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0009XAllopathic & Osteopathic PhysiciansOphthalmologyGlaucoma Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR210764001Medicaid
MS04974576Medicaid
TNP01621977OtherRR MEDICARE
TNQ013926Medicaid
MSP01601629OtherRR MEDICARE
MSP01601629OtherRR MEDICARE
AR210764001Medicaid
MS436533YKE0Medicare PIN