Provider Demographics
NPI:1245201508
Name:PETERSON, PRESTON LANE (MD)
Entity Type:Individual
Prefix:DR
First Name:PRESTON
Middle Name:LANE
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 NW VAUGHN ST
Mailing Address - Street 2:SUITE 160
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-5311
Mailing Address - Country:US
Mailing Address - Phone:503-499-5200
Mailing Address - Fax:503-499-5455
Practice Address - Street 1:2701 NW VAUGHN ST
Practice Address - Street 2:SUITE 160
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-5311
Practice Address - Country:US
Practice Address - Phone:503-499-5200
Practice Address - Fax:503-499-5455
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60167468207RG0300X
ORMD25733207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORI37471Medicare UPIN