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NPI Code Detail

MEDICARE: DR. BRYAN LUCAS PETERSON D.O.

MEDICARE: DR. BRYAN LUCAS PETERSON D.O.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12085R0202XDiagnostic Radiology Physician2020-04511NC
22085R0202XDiagnostic Radiology PhysicianOS14808FL
3208D00000XGeneral Practice PhysicianUO3382FL
42085R0202XDiagnostic Radiology PhysicianUO3382FL
52085R0202XDiagnostic Radiology Physician36552MS

General Provider Information

NPI Number : 1831436591
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. BRYAN LUCAS PETERSON D.O.
Provider Business Mailing Address
First Line : 350 N HUMPHREYS BLVD
Second Line :
City : MEMPHIS
State : TN
Zip : 38120-2177
Country : US
Telephone Number : 901-226-4003
Fax Number :
Provider Business Practice Location Address
First Line : 2520 5TH ST N
Second Line :
City : COLUMBUS
State : MS
Zip : 39705-2008
Country : US
Telephone Number : 662-244-1584
Fax Number : 662-244-2086
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/14/2013
Last Update Date : 05/08/2026

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