MEDICARE: JON D PETERS M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist		VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1505687000	OTHER	DC	US DOL WC
2	45710002	OTHER	DC	CF DC
3	223963	OTHER	VA	ANTHEM BC BS
4	283598	OTHER	VA	AMERIGROUP
5	4054667	OTHER	VA	AETNA
6	505094	OTHER	VA	NCPPO
7	46389	OTHER	VA	ALLIANCE
8	53508702	OTHER	MD	CF MD REGIONAL RENDERING
9	0500039	OTHER	VA	ONITED HEALTHCARE
10	46389	OTHER	VA	MAMSI

General Provider Information

NPI Number	:	1689776106
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JON D PETERS M.D.

Provider Business Mailing Address
First Line	:	PO BOX 79429
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21279-0429
Country	:	US
Telephone Number	:	301-624-5731
Fax Number	:

Provider Business Practice Location Address
First Line	:	12007 SUNRISE VALLEY DR
Second Line	:	SUITE 120
City	:	RESTON
State	:	VA
Zip	:	20191-3479
Country	:	US
Telephone Number	:	301-624-5731
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/04/2006
Last Update Date	:	07/08/2007

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Directions to “ JON D PETERS M.D.” Practice Location

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