Provider Demographics
NPI:1255319828
Name:PETERSON M.D., MATTHEW SHANE (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:SHANE
Last Name:PETERSON M.D.
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 1:1145 19TH ST NW
Mailing Address - Street 2:SUITE 410
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20036-3701
Mailing Address - Country:US
Mailing Address - Phone:202-331-1740
Mailing Address - Fax:202-296-9784
Practice Address - Street 1:1145 19TH ST NW
Practice Address - Street 2:SUITE 410
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20036-3701
Practice Address - Country:US
Practice Address - Phone:202-331-1740
Practice Address - Fax:202-296-9784
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200200772207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89132R9Medicaid
NCH72956Medicare UPIN
NC2007940AMedicare ID - Type Unspecified