Provider Demographics
NPI:1942205349
Name:PETERSON, CELESTE V (DO)
Entity Type:Individual
Prefix:DR
First Name:CELESTE
Middle Name:V
Last Name:PETERSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 850
Mailing Address - Street 2:
Mailing Address - City:ROGERSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37857-0850
Mailing Address - Country:US
Mailing Address - Phone:423-727-6319
Mailing Address - Fax:423-727-4164
Practice Address - Street 1:222 OAK ST
Practice Address - Street 2:
Practice Address - City:MOUNTAIN CITY
Practice Address - State:TN
Practice Address - Zip Code:37683-1526
Practice Address - Country:US
Practice Address - Phone:423-727-6319
Practice Address - Fax:423-727-4164
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2010-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN827207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3300550Medicaid
TN4085169OtherBCBST
TN3300550Medicaid
3300550Medicare ID - Type Unspecified
TN4085169OtherBCBST
3703867Medicare PIN
3703865Medicare PIN
D15051Medicare UPIN