Healthcare Provider Details

I. General information

NPI: 1902900517
Provider Name (Legal Business Name): GARY J PETERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 05/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10012 KENNERLY RD SUITE 305
SAINT LOUIS MO
63128-2197
US

IV. Provider business mailing address

10012 KENNERLY RD SUITE 305
SAINT LOUIS MO
63128-2197
US

V. Phone/Fax

Practice location:
  • Phone: 314-525-4325
  • Fax: 314-525-4365
Mailing address:
  • Phone: 314-525-4325
  • Fax: 314-525-4365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberR5836
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: