Provider Demographics
NPI:1093773160
Name:PETERSON, JOLYON DAVID (MD)
Entity Type:Individual
Prefix:
First Name:JOLYON
Middle Name:DAVID
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:J.
Other - Middle Name:DAVID
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1501 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-3302
Mailing Address - Country:US
Mailing Address - Phone:253-680-6016
Mailing Address - Fax:
Practice Address - Street 1:1501 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-3302
Practice Address - Country:US
Practice Address - Phone:253-680-6016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA12819207P00000X
WAMD00012819207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8288003Medicaid
WA8288003Medicaid
WAAB17910Medicare ID - Type Unspecified