Provider Demographics
NPI:1891703021
Name:PETERS, GERALD E JR (MD)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:E
Last Name:PETERS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:2041 NE WILLIAMSON CT
Mailing Address - Street 2:STE B
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-3925
Mailing Address - Country:US
Mailing Address - Phone:541-323-7546
Mailing Address - Fax:541-541-3234
Practice Address - Street 1:2041 NE WILLIAMSON CT
Practice Address - Street 2:STE B
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-3925
Practice Address - Country:US
Practice Address - Phone:541-323-7546
Practice Address - Fax:541-541-3234
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORMD25927207N00000X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR269917Medicaid
OR00479104OtherMEDICARE RAILROAD
ORR135737Medicare Oscar/Certification
OR269917Medicaid
ORR135737Medicare PIN