Provider Demographics
NPI:1124137955
Name:PETERS, TIMOTHY J (DC)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:J
Last Name:PETERS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:562 W 12TH
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-3509
Mailing Address - Country:US
Mailing Address - Phone:701-483-1104
Mailing Address - Fax:701-483-1443
Practice Address - Street 1:562 12TH ST W
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-3509
Practice Address - Country:US
Practice Address - Phone:701-483-1104
Practice Address - Fax:701-483-1443
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND564111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND17920Medicaid
ND12125OtherBLUE CROSS BLUE SHIELD
NDN12125Medicare PIN
NDU47407Medicare UPIN
ND12125Medicare ID - Type Unspecified
ND6008970001Medicare NSC