Provider Demographics
NPI:1215939137
Name:PETERSON, DONALD LEON (OD)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:LEON
Last Name:PETERSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:813 SW HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-3123
Mailing Address - Country:US
Mailing Address - Phone:541-548-7170
Mailing Address - Fax:
Practice Address - Street 1:813 SW HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-3123
Practice Address - Country:US
Practice Address - Phone:541-548-7170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1290T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR236067Medicaid
A002OtherCHAMPUS
WAG8860954Medicare PIN
WAG8860953Medicare PIN
WAG8860955Medicare PIN
AKK160821Medicare PIN
ORR135003Medicare PIN
MT0483956Medicare PIN
OR236067Medicaid
WAG8860957Medicare PIN
WAG8860952Medicare PIN
WAG8860956Medicare PIN
T44378Medicare UPIN
ID1591840Medicare PIN