Healthcare Provider Details

I. General information

NPI: 1023111002
Provider Name (Legal Business Name): JOHN CLEVE PETERSON III M.D., M.P.H.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7030 N MERCER WAY
MERCER ISLAND WA
98040-2130
US

IV. Provider business mailing address

7030 N MERCER WAY
MERCER ISLAND WA
98040-2130
US

V. Phone/Fax

Practice location:
  • Phone: 206-232-7669
  • Fax: 206-232-7679
Mailing address:
  • Phone: 206-232-7669
  • Fax: 206-232-7679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number11059
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number11059
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: