Healthcare Provider Details

I. General information

NPI: 1194868596
Provider Name (Legal Business Name): MYRON B PETERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CATO LTD. 1100 WINTER STREET
WALTHAM MA
02451
US

IV. Provider business mailing address

71 OAK STREET
BELMONT MA
02478
US

V. Phone/Fax

Practice location:
  • Phone: 617-484-2297
  • Fax:
Mailing address:
  • Phone: 617-484-2297
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number41235
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: