Individual
RANDOLPH E PETERSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
840 SW 4TH AVE, ONTARIO, OR 97914-2627
(541) 889-2899
(541) 889-2883
Mailing address
PO BOX 1460, ONTARIO, OR 97914-1066
(541) 889-2899
(541) 889-2883
Taxonomy
Speciality
Code
Description
License number
State
207X00000X
Orthopaedic Surgery Physician
Primary
19969
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
003426400
IDAHO MEDICAID EDS
ID
05
—
135827
—
OR
01
—
838281001
BCBS OF OR
OR
Enumeration date
10/17/2005
Last updated
07/08/2007
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