Provider Demographics
NPI:1982688388
Name:PETERSON, DOUGLAS GEORGE (DC)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:GEORGE
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3030 SW MOODY AVE
Mailing Address - Street 2:STE 102
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-4867
Mailing Address - Country:US
Mailing Address - Phone:503-224-2225
Mailing Address - Fax:503-222-3883
Practice Address - Street 1:3030 SW MOODY AVE
Practice Address - Street 2:STE 102
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-4867
Practice Address - Country:US
Practice Address - Phone:503-224-2225
Practice Address - Fax:503-222-3883
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR271570111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
R118022Medicare ID - Type Unspecified
U98794Medicare UPIN