Basic Information
| Provider Information | |||||||||
| NPI: | 1639157191 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERS | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 728 134TH ST SW | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982045322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252976200 | ||||||||
| FaxNumber: | 4252976250 | ||||||||
| Practice Location | |||||||||
| Address1: | 1321 COLBY AVENUE | ||||||||
| Address2: | PROVIDENCE EVERETT MEDICAL CENTER | ||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252612000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2006 | ||||||||
| LastUpdateDate: | 12/07/2007 | ||||||||
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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 | 2085R0202X | MD00017156 | WA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 115853 | 01 | WA | L&I PROVIDER NUMBER | OTHER | 202193 | 01 | WA | L&I PROVIDER NUMBER | OTHER | 202192 | 01 | WA | L&I PROVIDER NUMBER | OTHER | 8197303 | 05 | WA | MEDICAID | P00368477 | 01 | WA | RR MEDICARE | OTHER |