Healthcare Provider Details

I. General information

NPI: 1619050424
Provider Name (Legal Business Name): DAVID A PETERSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 01/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2315 8TH ST
LEWISTON ID
83501-7301
US

IV. Provider business mailing address

2315 8TH ST
LEWISTON ID
83501-7301
US

V. Phone/Fax

Practice location:
  • Phone: 208-746-1383
  • Fax: 208-746-6348
Mailing address:
  • Phone: 208-746-1383
  • Fax: 208-746-6348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM4779
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD00026059
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: