Healthcare Provider Details

I. General information

NPI: 1982048617
Provider Name (Legal Business Name): LAURA SUSAN PETERSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2013
Last Update Date: 08/11/2021
Certification Date: 08/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 BURNET AVE ML 7009
CINCINNATI OH
45229-3026
US

IV. Provider business mailing address

3333 BURNET AVE ML 5021
CINCINNATI OH
45229-3026
US

V. Phone/Fax

Practice location:
  • Phone: 513-636-4830
  • Fax: 513-636-7868
Mailing address:
  • Phone: 513-636-4225
  • Fax: 513-636-2511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA149465
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301105416
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberA149465
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number35.142997
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: