Provider Demographics
NPI:1992279756
Name:PETERSON, ALEC
Entity type:Individual
Prefix:
First Name:ALEC
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 NW 24TH ST APT C
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73103-3228
Mailing Address - Country:US
Mailing Address - Phone:918-991-5231
Mailing Address - Fax:
Practice Address - Street 1:4825 NW 23RD ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73127-1800
Practice Address - Country:US
Practice Address - Phone:405-482-0313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-15
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1477914166OtherLANDMARK RECOVERY