Healthcare Provider Details

I. General information

NPI: 1336491612
Provider Name (Legal Business Name): DOUGLAS E. PETERSON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2012
Last Update Date: 12/14/2021
Certification Date: 12/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 STATE RD
DANVERS MA
01923-2567
US

IV. Provider business mailing address

4 STATE RD
DANVERS MA
01923-2567
US

V. Phone/Fax

Practice location:
  • Phone: 978-774-3400
  • Fax: 978-774-5883
Mailing address:
  • Phone: 978-774-3400
  • Fax: 978-774-5883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number153208
License Number StateMA

VIII. Authorized Official

Name: DR. DOUGLAS EDWARD PETERSON
Title or Position: ORTHOPEDIC SURGEON
Credential: D.O.
Phone: 978-774-3400