Healthcare Provider Details

I. General information

NPI: 1497250252
Provider Name (Legal Business Name): DR. ERIC LEE PETERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2018
Last Update Date: 08/11/2022
Certification Date: 08/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

426 W MAIN ST
SALEM VA
24153-3610
US

IV. Provider business mailing address

PO BOX 1789
ROANOKE VA
24008-1789
US

V. Phone/Fax

Practice location:
  • Phone: 540-855-5100
  • Fax: 540-387-3349
Mailing address:
  • Phone: 540-855-5100
  • Fax: 540-387-3349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number0101275027
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: