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General NPI Number Information
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NPI Number | 1730341264
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Entity Type | Individual
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Provider Name | LESLIE MICHAEL PETERSON D.O.
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Gender | Male
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Dates
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Enumeration Date | 06/26/2008
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Last Update Date | 01/21/2014
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Provider Practice Location Address
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Address Line | 501 MORRIS ST FL 5
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City | CHARLESTON
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State | WV
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Zip | 25301-1326
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Country | US
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Telephone | 304-388-7170
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Fax | 304-388-1858
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Provider Business Mailing Address
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Address Line | 501 MORRIS ST FL 5
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City | CHARLESTON
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State | WV
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Zip | 25301-1326
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Country | US
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Telephone | 304-388-7170
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Fax | 304-388-1858
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | 2410
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License Number State | WV
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