Provider Demographics
NPI:1023037736
Name:PETERSON, JOHN DONALD (DC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DONALD
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1454 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ALBERT LEA
Mailing Address - State:MN
Mailing Address - Zip Code:56007-1816
Mailing Address - Country:US
Mailing Address - Phone:507-373-0120
Mailing Address - Fax:507-373-4395
Practice Address - Street 1:1454 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ALBERT LEA
Practice Address - State:MN
Practice Address - Zip Code:56007-1816
Practice Address - Country:US
Practice Address - Phone:507-373-0120
Practice Address - Fax:507-373-4395
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1765111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor