Healthcare Provider Details

I. General information

NPI: 1396743548
Provider Name (Legal Business Name): DONALD DOUGLAS PETERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 08/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 8TH ST 1ST FLOOR
NORTH WILKESBORO NC
28659-4167
US

IV. Provider business mailing address

PO BOX 159
NORTH WILKESBORO NC
28659-0159
US

V. Phone/Fax

Practice location:
  • Phone: 336-838-4158
  • Fax: 336-838-5361
Mailing address:
  • Phone: 336-838-4158
  • Fax: 336-838-5361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number21502
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: