MEDICARE: MITCHELL JAY 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	207Q00000X	Family Medicine Physician	MD00031099	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1770526626
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MITCHELL JAY PETERSON M.D.

Provider Business Mailing Address
First Line	:	1145 BROADWAY
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98122-4201
Country	:	US
Telephone Number	:	206-329-1760
Fax Number	:

Provider Business Practice Location Address
First Line	:	11011 MERIDIAN AVE N
Second Line	:	SUITE 200
City	:	SEATTLE
State	:	WA
Zip	:	98133-8967
Country	:	US
Telephone Number	:	206-525-5777
Fax Number	:

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

Provider Enumeration Date	:	06/14/2006
Last Update Date	:	03/24/2008

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