Healthcare Provider Details

I. General information

NPI: 1154510998
Provider Name (Legal Business Name): DR TIMOTHY PETERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2007
Last Update Date: 10/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 WELCH ST
SILVERTON OR
97381-1946
US

IV. Provider business mailing address

605 WELCH ST
SILVERTON OR
97381-1946
US

V. Phone/Fax

Practice location:
  • Phone: 503-873-6987
  • Fax: 503-873-8923
Mailing address:
  • Phone: 503-873-6987
  • Fax: 503-873-8923

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberMD17287
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberMD17287
License Number StateOR

VIII. Authorized Official

Name: DR. TIMOTHY ROY PETERS
Title or Position: OWNER
Credential: MD
Phone: 503-873-6987