Provider Demographics
NPI:1922068576
Name:PETERSON, LAURA LYNNE (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:LYNNE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 CENTRAL ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01772-1626
Mailing Address - Country:US
Mailing Address - Phone:508-229-0668
Mailing Address - Fax:
Practice Address - Street 1:2014 WASHINGTON STREET
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02462
Practice Address - Country:US
Practice Address - Phone:617-243-6040
Practice Address - Fax:617-243-6924
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA73351207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
073351OtherTUFTS
44563OtherHP
J10680OtherBLUE SHIELD
MA3073530Medicaid
J10680Medicare ID - Type Unspecified
44563OtherHP