Healthcare Provider Details

I. General information

NPI: 1992315311
Provider Name (Legal Business Name): PETERSON METELLUS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2020
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1545 ATLANTIC AVE
BROOKLYN NY
11213-1122
US

IV. Provider business mailing address

1545 ATLANTIC AVE
BROOKLYN NY
11213-1122
US

V. Phone/Fax

Practice location:
  • Phone: 732-584-3500
  • Fax:
Mailing address:
  • Phone: 718-613-6805
  • Fax: 937-466-0972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number323900
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License Number323900
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: