Provider Demographics
NPI:1043273907
Name:PETERSON, LARRY LEN (MD)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:LEN
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 1:16877 65TH AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-7865
Mailing Address - Country:US
Mailing Address - Phone:503-620-3376
Mailing Address - Fax:503-684-8554
Practice Address - Street 1:16877 65TH AVE
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-7865
Practice Address - Country:US
Practice Address - Phone:503-620-3376
Practice Address - Fax:503-684-8554
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD12848207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR3542298OtherLIFEWISE