Healthcare Provider Details

I. General information

NPI: 1508392366
Provider Name (Legal Business Name): ERIN PETERSEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 03/04/2021
Certification Date: 03/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3631 BIENVILLE BLVD
OCEAN SPRINGS MS
39564-5702
US

IV. Provider business mailing address

3631 BIENVILLE BLVD
OCEAN SPRINGS MS
39564-5702
US

V. Phone/Fax

Practice location:
  • Phone: 228-875-2020
  • Fax: 228-875-2036
Mailing address:
  • Phone: 228-875-2020
  • Fax: 228-875-2036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberT-3405
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number27698
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: