Provider Demographics
NPI:1134211568
Name:PETERSON, TIMOTHY A (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:A
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 5210
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58206-5210
Mailing Address - Country:US
Mailing Address - Phone:701-205-3000
Mailing Address - Fax:701-732-2501
Practice Address - Street 1:4700 S WASHINGTON ST STE G
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-8123
Practice Address - Country:US
Practice Address - Phone:701-205-3000
Practice Address - Fax:701-732-2501
Is Sole Proprietor?:No
Enumeration Date:2006-09-30
Last Update Date:2025-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND77772084P0800X, 2083A0300X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1694259Medicaid
ND1456145Medicaid