Healthcare Provider Details

I. General information

NPI: 1710392477
Provider Name (Legal Business Name): SHAWN PETERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2014
Last Update Date: 12/07/2020
Certification Date: 12/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 NICHOLASVILLE RD STE 1100
LEXINGTON KY
40503-1466
US

IV. Provider business mailing address

5200 COMMERCE CROSSING 3RD FLOOR
LOUISVILLE KY
40229-2182
US

V. Phone/Fax

Practice location:
  • Phone: 859-276-0414
  • Fax:
Mailing address:
  • Phone: 502-253-4900
  • Fax: 502-489-5751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberR3588
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License Number50117
License Number StateKY
# 4
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number50117
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: