=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851377956
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAROLINE E PETERSON DO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2005
-----------------------------------------------------
Last Update Date | 01/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7756 WASHINGTON VILLAGE DR STE 135
-----------------------------------------------------
City | CENTERVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45459-3999
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-425-4137
-----------------------------------------------------
Fax | 937-425-4139
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 PRESTIGE PL STE 550
-----------------------------------------------------
City | MIAMISBURG
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45342-6115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-762-1310
-----------------------------------------------------
Fax | 937-522-8493
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 34005030
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------