Individual
DR. JED RUSSELL PETERSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
10123 SE MARKET ST, DEPARTMENT OF RADIOLOGY, PORTLAND, OR 97216-2532
(503) 251-6137
(503) 261-6058
Mailing address
10123 SE MARKET ST, DEPARTMENT OF RADIOLOGY, PORTLAND, OR 97216-2532
(503) 251-6137
(503) 261-6058
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
157199
OR
2085R0202X
Diagnostic Radiology Physician
MD.60212410
WA
2085R0204X
Vascular & Interventional Radiology Physician
Primary
157199
OR
2085R0204X
Vascular & Interventional Radiology Physician
MD.60212410
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
157199
OREGON MEDICAL BOARD
OR
01
—
MD60212410
MEDICAL LICENSE NUMBER
WA
Enumeration date
05/04/2007
Last updated
10/15/2012
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