Provider Demographics
NPI:1942307301
Name:PETERSON, DAVID WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:WILLIAM
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 1:32 PHYSICIAN DR
Mailing Address - Street 2:
Mailing Address - City:CLYDE
Mailing Address - State:NC
Mailing Address - Zip Code:28721-8486
Mailing Address - Country:US
Mailing Address - Phone:828-564-9222
Mailing Address - Fax:828-564-9200
Practice Address - Street 1:32 PHYSICIAN DR
Practice Address - Street 2:
Practice Address - City:CLYDE
Practice Address - State:NC
Practice Address - Zip Code:28721-8486
Practice Address - Country:US
Practice Address - Phone:828-564-9222
Practice Address - Fax:828-564-9228
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9801441174400000X
NC132483207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No174400000XOther Service ProvidersSpecialist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89126HPMedicaid
NCF86263Medicare UPIN
NC2075995Medicare PIN
NC2280046DMedicare PIN