Basic Information
| Provider Information | |||||||||
| NPI: | 1255319828 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON M.D. | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | SHANE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1145 19TH ST NW | ||||||||
| Address2: | SUITE 410 | ||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200363701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2023311740 | ||||||||
| FaxNumber: | 2022969784 | ||||||||
| Practice Location | |||||||||
| Address1: | 1145 19TH ST NW | ||||||||
| Address2: | SUITE 410 | ||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200363701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2023311740 | ||||||||
| FaxNumber: | 2022969784 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2006 | ||||||||
| LastUpdateDate: | 01/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 200200772 | NC | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 89132R9 | 05 | NC | MEDICAID |