Provider Demographics
NPI:1053336354
Name:PETERSON, PAUL ARNOLD (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:ARNOLD
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:PO BOX 4105
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4105
Mailing Address - Country:US
Mailing Address - Phone:907-212-7997
Mailing Address - Fax:907-212-8225
Practice Address - Street 1:3300 PROVIDENCE DR STE B-104
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4690
Practice Address - Country:US
Practice Address - Phone:607-212-7997
Practice Address - Fax:907-212-8225
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2023-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2641207RC0000X, 207RI0011X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1011916Medicaid
AK060051650OtherRAILROAD MEDICARE
AK060051650OtherRAILROAD MEDICARE
AKB55713Medicare UPIN