Provider Demographics
NPI:1992751325
Name:PETERSON, ALAN CLIFTON (MD)
Entity type:Individual
Prefix:DR
First Name:ALAN
Middle Name:CLIFTON
Last Name:PETERSON
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 1:415 6TH ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-2431
Mailing Address - Country:US
Mailing Address - Phone:208-746-0516
Mailing Address - Fax:208-746-4989
Practice Address - Street 1:415 6TH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2431
Practice Address - Country:US
Practice Address - Phone:208-746-0516
Practice Address - Fax:208-746-4989
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-9571207ZP0102X
WAMD00046440207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807462200Medicaid
KSH94977Medicare UPIN