Provider Demographics
NPI:1649206558
Name:PETERSON, DONALD THORGEIR (DPM)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:THORGEIR
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8029 JERICHO TPKE
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11797-1212
Mailing Address - Country:US
Mailing Address - Phone:516-496-0900
Mailing Address - Fax:516-496-0901
Practice Address - Street 1:8029 JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NY
Practice Address - Zip Code:11797-1212
Practice Address - Country:US
Practice Address - Phone:516-496-0900
Practice Address - Fax:516-496-0901
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN4585213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY013496283Medicaid
NYP50401Medicare ID - Type Unspecified
NY013496283Medicaid