Provider Demographics
NPI:1467474916
Name:PETERSEN, RANDALL K (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:K
Last Name:PETERSEN
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 1:11811 NE 128TH ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-7200
Mailing Address - Country:US
Mailing Address - Phone:425-250-1145
Mailing Address - Fax:425-823-6028
Practice Address - Street 1:1310 116TH AVE NE
Practice Address - Street 2:SUITE E
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3817
Practice Address - Country:US
Practice Address - Phone:425-250-1145
Practice Address - Fax:425-823-6028
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000294392085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8140261Medicaid
WA8140261Medicaid
WAF22565Medicare UPIN