Provider Demographics
NPI:1154409316
Name:PETERSEN, ARNOLD L II (MD)
Entity type:Individual
Prefix:DR
First Name:ARNOLD
Middle Name:L
Last Name:PETERSEN
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 33977
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97292-3977
Mailing Address - Country:US
Mailing Address - Phone:503-256-0890
Mailing Address - Fax:503-255-2150
Practice Address - Street 1:10101 SE MAIN ST STE 2001
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2457
Practice Address - Country:US
Practice Address - Phone:503-256-0890
Practice Address - Fax:503-255-2150
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR07945207Q00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR151084Medicaid
C93510Medicare UPIN
OR151084Medicaid