Provider Demographics
NPI:1639253529
Name:PETERSON, JAMES WILSON (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:WILSON
Last Name:PETERSON
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 1:3320 WAKE FOREST RD., SUITE 200
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609
Mailing Address - Country:US
Mailing Address - Phone:919-862-5100
Mailing Address - Fax:919-862-5104
Practice Address - Street 1:3320 WAKE FOREST RD., SUITE 200
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609
Practice Address - Country:US
Practice Address - Phone:919-862-5100
Practice Address - Fax:919-862-5104
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2004-00945207RC0000X
NC200400945207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89137PKMedicaid
F83394Medicare UPIN
2033158Medicare PIN