Provider Demographics
NPI:1700809878
Name:PETERSON, DONALD R II (MD, INC)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:R
Last Name:PETERSON
Suffix:II
Gender:M
Credentials:MD, INC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 408
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-0408
Mailing Address - Country:US
Mailing Address - Phone:916-622-3609
Mailing Address - Fax:916-961-0301
Practice Address - Street 1:4219 BUCHANAN DR
Practice Address - Street 2:
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-6105
Practice Address - Country:US
Practice Address - Phone:166-223-6099
Practice Address - Fax:916-780-1679
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG22928208D00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
00G229280Medicare ID - Type Unspecified
CAA41778Medicare UPIN