Provider Demographics
NPI:1619362001
Name:PETERSON, SEAN LUKE (MD)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:LUKE
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SEAN
Other - Middle Name:LUKE
Other - Last Name:WEINBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:10180 SE SUNNYSIDE RD OFC
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-8970
Mailing Address - Country:US
Mailing Address - Phone:503-813-2000
Mailing Address - Fax:
Practice Address - Street 1:10180 SE SUNNYSIDE RD OFC EGS
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-8970
Practice Address - Country:US
Practice Address - Phone:503-813-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-02
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61103323208600000X
MN63579208600000X
IAMD47700208600000X
WI73695-20208600000X
390200000X
ORMD201352208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program