Provider Demographics
NPI:1013931997
Name:PETERSON, JOHN G (MD, FACC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:G
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD, FACC
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 331
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0331
Mailing Address - Country:US
Mailing Address - Phone:866-747-2455
Mailing Address - Fax:
Practice Address - Street 1:212 E CENTRAL AVE
Practice Address - Street 2:SUITE 240
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-6291
Practice Address - Country:US
Practice Address - Phone:509-455-8820
Practice Address - Fax:509-838-4978
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00032074207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA060056517OtherRRB
ID805511702Medicaid
WA8240657Medicaid
ID1142720Medicare PIN
WAGAB08883Medicare PIN
WA060056517OtherRRB