Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207QA0505X | Family Doctor - Adult Medicine | 11059 | WA |
N | 207RG0300X | Geriatric Medicine | 11059 | WA |
NPI | 1023111002 |
---|---|
Provider Name | Dr. John Cleve Peterson III |
First Address | Mercer Island, WA 98040-2130 |
Second Address | Mercer Island, WA 98040-2130 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/09/2006 |
Last Update Date | 08/07/2007 |