Provider Demographics
NPI:1053904672
Name:PETERSON, JARED DAVID
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:DAVID
Last Name:PETERSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DEPARTMENT OF OPHTHALMOLOGY MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27157-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1040 NW 22ND AVE STE 168
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3036
Practice Address - Country:US
Practice Address - Phone:503-413-7022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-15
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC390200000X
ORMD224449207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program