Provider Demographics
NPI:1972071777
Name:PETERSON, DOUGLAS (MSC, LAC)
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MSC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 E 58TH ST APT 21D
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-2379
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:333 E 46TH ST APT 1J
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10017-7426
Practice Address - Country:US
Practice Address - Phone:917-217-8391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-09
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006347-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist