Provider Demographics
NPI:1194709162
Name:PETERS, DONALD WALTER (MD)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:WALTER
Last Name:PETERS
Suffix:
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 602658
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2658
Mailing Address - Country:US
Mailing Address - Phone:336-716-2011
Mailing Address - Fax:
Practice Address - Street 1:791 JONESTOWN RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1252
Practice Address - Country:US
Practice Address - Phone:336-716-3693
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC286082084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV203711000Medicaid
29247OtherMEDCOST
NC8967165Medicaid
67165OtherBCBS
260050043OtherRR MEDICARE
5457218OtherAETNA
SCQ28608Medicaid
4757OtherPARTNERS
VA7140291Medicaid
NC8967165Medicaid
29247OtherMEDCOST