Healthcare Provider Details

I. General information

NPI: 1598780553
Provider Name (Legal Business Name): TED STEVEN PETERSON DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 07/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 E GARFIELD RD
AURORA OH
44202-6713
US

IV. Provider business mailing address

10440 WYE ROAD
CHESTERLAND OH
44026-3326
US

V. Phone/Fax

Practice location:
  • Phone: 330-562-2211
  • Fax:
Mailing address:
  • Phone: 440-285-9086
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number36.001787
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: