Provider Demographics
NPI:1871954214
Name:PETERS DERMATOLOGY CENTER
Entity type:Organization
Organization Name:PETERS DERMATOLOGY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:MR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:541-323-7546
Mailing Address - Street 1:2041 NE WILLIAMSON CT
Mailing Address - Street 2:STE B
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-3925
Mailing Address - Country:US
Mailing Address - Phone:541-323-7546
Mailing Address - Fax:541-323-4997
Practice Address - Street 1:2041 NE WILLIAMSON CT
Practice Address - Street 2:STE B
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-3925
Practice Address - Country:US
Practice Address - Phone:541-323-7546
Practice Address - Fax:541-323-4997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-13
Last Update Date:2016-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD25927207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty