Individual
CHARLES D PETERSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
3535 SOUTHERN BLVD, KETTERING, OH 45429-1221
(937) 296-7211
Mailing address
PO BOX 292796, KETTERING, OH 45429-8796
(614) 430-5726
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
35053561
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0775951
—
OH
01
—
360003376
MEDICARE RAILROAD
—
Enumeration date
05/25/2006
Last updated
08/18/2011
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