Basic Information
| Provider Information | |||||||||
| NPI: | 1083621312 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERS | ||||||||
| FirstName: | JON | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 10151 SE SUNNYSIDE RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | CLACKAMAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970155705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036590880 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10151 SE SUNNYSIDE RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | CLACKAMAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970155705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036590880 | ||||||||
| FaxNumber: | 5035137425 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 05/11/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD18051 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 050471 | 05 | OR | MEDICAID | 080061183 | 01 | OR | RAILROAD MEDICARE PIN | OTHER | 8125841 | 05 | WA | MEDICAID | 048194004 | 01 | OR | BLUE CROSS BLUE SHIELD | OTHER |