Provider Demographics
NPI:1831436591
Name:PETERSON, BRYAN LUCAS (DO)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:LUCAS
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7944 SW 195TH TER
Mailing Address - Street 2:
Mailing Address - City:CUTLER BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-8129
Mailing Address - Country:US
Mailing Address - Phone:972-814-9266
Mailing Address - Fax:
Practice Address - Street 1:722 NEWMAN RD
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562-5238
Practice Address - Country:US
Practice Address - Phone:252-633-5057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-14
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLUO33822085R0202X, 208D00000X
FLOS148082085R0202X
NC2020-045112085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice