Provider Demographics
NPI:1164634770
Name:PETERSON, JED RUSSELL (MD)
Entity Type:Individual
Prefix:DR
First Name:JED
Middle Name:RUSSELL
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:10123 SE MARKET ST
Mailing Address - Street 2:DEPARTMENT OF RADIOLOGY
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-2532
Mailing Address - Country:US
Mailing Address - Phone:503-251-6137
Mailing Address - Fax:503-261-6058
Practice Address - Street 1:10123 SE MARKET ST
Practice Address - Street 2:DEPARTMENT OF RADIOLOGY
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2532
Practice Address - Country:US
Practice Address - Phone:503-251-6137
Practice Address - Fax:503-261-6058
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD.602124102085R0202X, 2085R0204X
OR1571992085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR157199OtherOREGON MEDICAL BOARD
WAMD60212410OtherMEDICAL LICENSE NUMBER