Healthcare Provider Details

I. General information

NPI: 1598294241
Provider Name (Legal Business Name): SHANNON CAESAR-PETERSON DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2017
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

628 ELDERT LN APT 5J
BROOKLYN NY
11208-3371
US

IV. Provider business mailing address

628 ELDERT LN APT 5J
BROOKLYN NY
11208-3371
US

V. Phone/Fax

Practice location:
  • Phone: 718-924-0570
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number322086
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: