Provider Demographics
NPI:1689776106
Name:PETERS, JON D (MD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:D
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:PO BOX 79429
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21279-0429
Mailing Address - Country:US
Mailing Address - Phone:301-624-5731
Mailing Address - Fax:
Practice Address - Street 1:12007 SUNRISE VALLEY DR
Practice Address - Street 2:SUITE 120
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191-3479
Practice Address - Country:US
Practice Address - Phone:301-624-5731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC1505687000OtherUS DOL WC
DC45710002OtherCF DC
VA223963OtherANTHEM BC BS
VA283598OtherAMERIGROUP
VA4054667OtherAETNA
VA505094OtherNCPPO
VA46389OtherALLIANCE
MD53508702OtherCF MD REGIONAL RENDERING
VA0500039OtherONITED HEALTHCARE
VA46389OtherMAMSI
DC45710002OtherCF DC
DC1505687000OtherUS DOL WC