Provider Demographics
NPI:1033558010
Name:PETERSON, JUSTIN WILLIAM (DO)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:WILLIAM
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DO
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 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:414-321-2255
Mailing Address - Fax:
Practice Address - Street 1:2424 S 90TH ST
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2455
Practice Address - Country:US
Practice Address - Phone:414-321-2255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-23
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI71467207X00000X
MI5101020737207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100091524Medicaid