Provider Demographics
NPI:1093779365
Name:PETERSON, ANDREW CLAIR (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:CLAIR
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1050 SW 3RD AVE
Mailing Address - Street 2:#3200
Mailing Address - City:ONTARIO
Mailing Address - State:OR
Mailing Address - Zip Code:97914-2193
Mailing Address - Country:US
Mailing Address - Phone:541-881-7373
Mailing Address - Fax:541-881-7186
Practice Address - Street 1:1050 SW 3RD AVE
Practice Address - Street 2:#3200
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-2193
Practice Address - Country:US
Practice Address - Phone:541-881-7373
Practice Address - Fax:541-881-7186
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMDO9438207R00000X
IDM6155207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003390300Medicaid
OR153049Medicaid
C93512Medicare UPIN
ID003390300Medicaid