Provider Demographics
NPI:1891744561
Name:PETERSON, ROD H (MD)
Entity Type:Individual
Prefix:
First Name:ROD
Middle Name:H
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:105 W 8TH AVE
Mailing Address - Street 2:SUITE 6055
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-2302
Mailing Address - Country:US
Mailing Address - Phone:509-455-9090
Mailing Address - Fax:509-747-2118
Practice Address - Street 1:105 W 8TH AVE
Practice Address - Street 2:SUITE 6055
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2302
Practice Address - Country:US
Practice Address - Phone:509-455-9090
Practice Address - Fax:509-747-2118
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-09
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000256002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2029663Medicaid