Iris Havlina Donovan Petersen, MD

Primary specialty

Pediatrics PhysicianTaxonomy code 208000000X

License

MD61140296 Issued in WA

Practice address

3434 12TH Ave NE
Olympia, WA 98506-5175

Phone

(360) 413-8470

NPI assigned

Apr 16, 2018

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in UT

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Olympia Pediatrics, PLLC

  • Specialist
  • Olympia, WA
  • NPI 1306012083
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1523836800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1628380800000",
    "number": "1659868560",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3434 12TH AVE NE",
            "city": "OLYMPIA",
            "state": "WA",
            "postal_code": "985065175",
            "telephone_number": "360-413-8470"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3434 12TH AVE NE",
            "city": "OLYMPIA",
            "state": "WA",
            "postal_code": "985065175",
            "telephone_number": "360-413-8470"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PETERSEN",
        "first_name": "IRIS",
        "middle_name": "HAVLINA DONOVAN",
        "name_prefix": "Dr.",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2018-04-16",
        "last_updated": "2021-08-08",
        "certification_date": "2021-08-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "UT",
            "license": "11405455-1205",
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "WA",
            "license": "MD61140296",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Jessica Rose Peters, D.C
• Lisa Mae Peters, CP60535132
• Nicole Peters
• Samantha Sue Petersen-Hobbs, CMHC
• Dana M Petersen, M.D.
• Morrigan Piper Petersen, CPC
• Anneliese Mendenhall Peterson, CPM, LM
• Bonnie Louise Peterson
• John E Peterson, OD
• Malgorzata Dymerska Peterson, MD

• Pediatrics Physician in Olympia, WA
• Providers in Olympia, WA by specialty
• Pediatrics Physician in Washington

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 8, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.