Provider Demographics
NPI:1396743548
Name:PETERSON, DONALD DOUGLAS (MD)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:DOUGLAS
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:PO BOX 159
Mailing Address - Street 2:
Mailing Address - City:NORTH WILKESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28659-0159
Mailing Address - Country:US
Mailing Address - Phone:336-838-4158
Mailing Address - Fax:336-838-5361
Practice Address - Street 1:408 8TH ST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:NORTH WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28659-4167
Practice Address - Country:US
Practice Address - Phone:336-838-4158
Practice Address - Fax:336-838-5361
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-12
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21502208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
10534OtherPARTNERS
67213OtherBCBS
299906OtherMAMSI
NC201833BOtherPSC MEDICARE PROVIDER
34550OtherMEDCOST
1907386OtherUHC
NC8967213Medicaid
6805098005OtherCIGNA
1907386OtherUHC
34550OtherMEDCOST