Healthcare Provider Details

I. General information

NPI: 1619362001
Provider Name (Legal Business Name): SEAN LUKE PETERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: SEAN LUKE WEINBERG M.D.

II. Dates (important events)

Enumeration Date: 04/02/2015
Last Update Date: 12/02/2021
Certification Date: 12/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10180 SE SUNNYSIDE RD OFC EGS
CLACKAMAS OR
97015-8970
US

IV. Provider business mailing address

10180 SE SUNNYSIDE RD OFC
CLACKAMAS OR
97015-8970
US

V. Phone/Fax

Practice location:
  • Phone: 503-813-2000
  • Fax:
Mailing address:
  • Phone: 503-813-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD61103323
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number63579
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD47700
License Number StateIA
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number73695-20
License Number StateWI
# 5
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD201352
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: