MEDICARE: DR. LARRY LEN PETERSON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	MD12848	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3542298	OTHER	OR	LIFEWISE

General Provider Information

NPI Number	:	1043273907
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LARRY LEN PETERSON M.D.

Provider Business Mailing Address
First Line	:	16877 65TH AVE
Second Line	:
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97035-7865
Country	:	US
Telephone Number	:	503-620-3376
Fax Number	:	503-684-8554

Provider Business Practice Location Address
First Line	:	16877 65TH AVE
Second Line	:
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97035-7865
Country	:	US
Telephone Number	:	503-620-3376
Fax Number	:	503-684-8554

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/10/2006
Last Update Date	:	07/08/2007

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