Healthcare Provider Details

I. General information

NPI: 1659698967
Provider Name (Legal Business Name): LUKE TYLER PETERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2010
Last Update Date: 03/01/2022
Certification Date: 03/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 CAMPUS RIDGE RD
MATTHEWS NC
28105-5077
US

IV. Provider business mailing address

4101 CAMPUS RIDGE RD
MATTHEWS NC
28105-5077
US

V. Phone/Fax

Practice location:
  • Phone: 404-295-6810
  • Fax: 833-231-6851
Mailing address:
  • Phone: 404-295-6810
  • Fax: 833-231-6851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number53018
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number23966
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number072079
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberE-9417
License Number StateAR
# 5
Primary TaxonomyN
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License NumberE9417
License Number StateAR
# 6
Primary TaxonomyN
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License NumberMD81655
License Number StateSC
# 7
Primary TaxonomyN
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License Number23966
License Number StateMS
# 8
Primary TaxonomyN
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License Number2018-02590
License Number StateNC
# 9
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number20018-02590
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: