Provider Demographics
NPI:1710392477
Name:PETERSON, SHAWN (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:
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 1:5200 COMMERCE CROSSING
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40229-2182
Mailing Address - Country:US
Mailing Address - Phone:502-253-4900
Mailing Address - Fax:502-489-5751
Practice Address - Street 1:1700 NICHOLASVILLE RD STE 1100
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-1466
Practice Address - Country:US
Practice Address - Phone:859-276-0414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-21
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR3588207R00000X
KY50117207RH0000X, 207RX0202X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100367380Medicaid