Provider Demographics
NPI:1033117205
Name:PETERS, ANTHONY D (DO)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:D
Last Name:PETERS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 E POLSTON AVE
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854
Mailing Address - Country:US
Mailing Address - Phone:208-773-1577
Mailing Address - Fax:208-773-8585
Practice Address - Street 1:1220 E POLSTON AVE
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854
Practice Address - Country:US
Practice Address - Phone:208-773-1577
Practice Address - Fax:208-773-8585
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID0-261208D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806064600Medicaid
1302319Medicare PIN
ID806064600Medicaid