Provider Demographics
NPI:1891780862
Name:PETERSON, PAUL CARL (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:CARL
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 1:501 20TH ST
Mailing Address - Street 2:SUITE 503
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37916
Mailing Address - Country:US
Mailing Address - Phone:865-541-4321
Mailing Address - Fax:865-541-4320
Practice Address - Street 1:501 20TH ST
Practice Address - Street 2:SUITE 503
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37916-1809
Practice Address - Country:US
Practice Address - Phone:865-541-4321
Practice Address - Fax:865-541-4320
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000027743207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3099553Medicaid
TN3099553Medicaid
TN3099553Medicare ID - Type Unspecified