Provider Demographics
NPI:1669461364
Name:PETERSON, RANDOLPH E (MD)
Entity Type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:E
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:PO BOX 1460
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OR
Mailing Address - Zip Code:97914-1066
Mailing Address - Country:US
Mailing Address - Phone:541-889-2899
Mailing Address - Fax:541-889-2883
Practice Address - Street 1:840 SW 4TH AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-2627
Practice Address - Country:US
Practice Address - Phone:541-889-2899
Practice Address - Fax:541-889-2883
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19969207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR135827Medicaid
OR838281001OtherBCBS OF OR
ID003426400OtherIDAHO MEDICAID EDS
OR838281001OtherBCBS OF OR
G31149Medicare UPIN