Provider Demographics
NPI:1619962990
Name:VONDOERSTEN, PETER GORDON (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:GORDON
Last Name:VONDOERSTEN
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:PO BOX 4907
Mailing Address - Street 2:700 WEST KENT
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59806-4907
Mailing Address - Country:US
Mailing Address - Phone:406-541-3277
Mailing Address - Fax:406-541-3950
Practice Address - Street 1:700 W KENT AVE
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-6772
Practice Address - Country:US
Practice Address - Phone:406-541-3277
Practice Address - Fax:406-541-3950
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT8110207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY118619100Medicaid
ID804154700Medicaid
MT0019773Medicaid
F26279Medicare UPIN
MT81780Medicare ID - Type Unspecified