Provider Demographics
NPI:1063642957
Name:PETERSON, CORNELIUS R (MD)
Entity Type:Individual
Prefix:DR
First Name:CORNELIUS
Middle Name:R
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:NEAL
Other - Middle Name:
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 4069
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98204-0007
Mailing Address - Country:US
Mailing Address - Phone:425-407-1000
Mailing Address - Fax:
Practice Address - Street 1:101 W 8TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2307
Practice Address - Country:US
Practice Address - Phone:509-474-3181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-25
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61305762207L00000X
KS9407283207R00000X, 207L00000X
NE27117207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine