Provider Demographics
NPI:1548478852
Name:PETERSON, DESMOND KIRK (ND)
Entity type:Individual
Prefix:DR
First Name:DESMOND
Middle Name:KIRK
Last Name:PETERSON
Suffix:
Gender:M
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2416 NW SCHMIDT WAY
Mailing Address - Street 2:#214
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-4661
Mailing Address - Country:US
Mailing Address - Phone:503-396-6697
Mailing Address - Fax:
Practice Address - Street 1:2416 NW SCHMIDT WAY
Practice Address - Street 2:#214
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-4661
Practice Address - Country:US
Practice Address - Phone:503-396-6697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0756175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath