Provider Demographics
NPI:1598780553
Name:PETERSON, TED STEVEN (DPM)
Entity type:Individual
Prefix:DR
First Name:TED
Middle Name:STEVEN
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10440 WYE ROAD
Mailing Address - Street 2:
Mailing Address - City:CHESTERLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44026-3326
Mailing Address - Country:US
Mailing Address - Phone:440-285-9086
Mailing Address - Fax:
Practice Address - Street 1:9 E GARFIELD RD
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:OH
Practice Address - Zip Code:44202-6713
Practice Address - Country:US
Practice Address - Phone:330-562-2211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36.001787213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0321904Medicaid
OH0321904Medicaid
OHT80426Medicare UPIN