Provider Demographics
NPI:1629284732
Name:PETERSON, CHAD ALLAN (MD)
Entity Type:Individual
Prefix:DR
First Name:CHAD
Middle Name:ALLAN
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:980 W IRONWOOD DR
Mailing Address - Street 2:STE. 104
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2668
Mailing Address - Country:US
Mailing Address - Phone:208-667-0621
Mailing Address - Fax:208-664-1709
Practice Address - Street 1:980 W IRONWOOD DR
Practice Address - Street 2:STE. 104
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2668
Practice Address - Country:US
Practice Address - Phone:208-667-0621
Practice Address - Fax:208-664-1709
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDM-10619208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology