Active NPI
Jon Peters, MD
- Family Medicine Physician
- Clackamas, OR
National Provider Identifier
1083621312
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- License
- MD18051
- Practice address
- 10151 SE Sunnyside Rd Ste 100
Clackamas, OR 97015-5705 - Phone
- (503) 659-0880
- Fax
- (503) 513-7425
- NPI assigned
- Aug 1, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | MD18051 | OR | Primary |
Addresses
Primary practice location
10151 SE Sunnyside Rd Ste 100
Clackamas, OR 97015-5705
Mailing address
10151 SE Sunnyside Rd Ste 100
Clackamas, OR 97015-5705
Phone (503) 659-0880
Other practice location 1
2647 NE 33rd Ave
Portland, OR 97212-3647
Phone (503) 288-0083
Other identifiers 4
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 050471 | Medicaid | OR | |
| 080061183 | Other | OR | RAILROAD MEDICARE PIN |
| 8125841 | Medicaid | WA | |
| 048194004 | Other | OR | BLUE CROSS BLUE SHIELD |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 18051 | OR | MD | Massage Therapist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1154390400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1620691200000",
"number": "1083621312",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "10151 SE SUNNYSIDE RD STE 100",
"city": "CLACKAMAS",
"state": "OR",
"postal_code": "970155705",
"telephone_number": "503-659-0880"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "10151 SE SUNNYSIDE RD STE 100",
"city": "CLACKAMAS",
"state": "OR",
"postal_code": "970155705",
"telephone_number": "503-659-0880",
"fax_number": "503-513-7425"
}
],
"practiceLocations": [
{
"address_1": "2647 NE 33rd Ave",
"address_purpose": "LOCATION",
"city": "Portland",
"state": "OR",
"postal_code": "972123647",
"country_code": "US",
"telephone_number": "503-288-0083",
"fax_number": "503-288-7843",
"country_name": "United States",
"address_type": "DOM"
}
],
"basic": {
"last_name": "PETERS",
"first_name": "JON",
"credential": "MD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-08-01",
"last_updated": "2021-05-11",
"certification_date": "2021-05-11",
"status": "A"
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "",
"desc": "Family Medicine",
"state": "OR",
"license": "MD18051",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "050471",
"state": "OR"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "RAILROAD MEDICARE PIN",
"identifier": "080061183",
"state": "OR"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "8125841",
"state": "WA"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BLUE CROSS BLUE SHIELD",
"identifier": "048194004",
"state": "OR"
}
],
"endpoints": [],
"other_names": []
}Other providers in Clackamas, OR
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 11, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.