Basic Information
| Provider Information | |||||||||
| NPI: | 1194709162 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERS | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | WALTER | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 602658 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282602658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367162011 | ||||||||
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| Practice Location | |||||||||
| Address1: | 791 JONESTOWN RD | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271031252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367163693 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2005 | ||||||||
| LastUpdateDate: | 04/02/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 28608 | NC | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 203711000 | 05 | WV | MEDICAID | 29247 | 01 | MEDCOST | OTHER | 8967165 | 05 | NC | MEDICAID | 67165 | 01 | BCBS | OTHER | 260050043 | 01 | RR MEDICARE | OTHER | 5457218 | 01 | AETNA | OTHER | Q28608 | 05 | SC | MEDICAID | 4757 | 01 | PARTNERS | OTHER | 7140291 | 05 | VA | MEDICAID |