Provider Demographics
NPI:1639157191
Name:PETERS, DONALD R (MD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:R
Last Name:PETERS
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 1:728 134TH ST SW
Mailing Address - Street 2:SUITE 120
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98204-5322
Mailing Address - Country:US
Mailing Address - Phone:425-297-6200
Mailing Address - Fax:425-297-6250
Practice Address - Street 1:1321 COLBY AVENUE
Practice Address - Street 2:PROVIDENCE EVERETT MEDICAL CENTER
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98206
Practice Address - Country:US
Practice Address - Phone:425-261-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000171562085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA115853OtherL&I PROVIDER NUMBER
WA202193OtherL&I PROVIDER NUMBER
WA202192OtherL&I PROVIDER NUMBER
WA8197303Medicaid
WAP00368477OtherRR MEDICARE
WAAB03750Medicare ID - Type UnspecifiedPROVIDER NUMBER
WA8197303Medicaid
WA115853OtherL&I PROVIDER NUMBER
WA8857072Medicare ID - Type UnspecifiedPROVIDER NUMBER
WA202193OtherL&I PROVIDER NUMBER