Provider Demographics
NPI:1841240991
Name:PETERSON, THOMAS T (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:T
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 1:5881 W 16TH ST
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-2910
Mailing Address - Country:US
Mailing Address - Phone:970-313-2740
Mailing Address - Fax:970-313-2744
Practice Address - Street 1:5881 W 16TH ST
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-2910
Practice Address - Country:US
Practice Address - Phone:970-313-2740
Practice Address - Fax:970-313-2744
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO27816207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01278167Medicaid
CO01278167Medicaid
COC65134Medicare PIN
CO268637YLB8Medicare PIN