Provider Demographics
NPI:1043413214
Name:PETERSON, JEREMY JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:JOHN
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 NORTHLAND DR
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:MN
Mailing Address - Zip Code:55371-2172
Mailing Address - Country:US
Mailing Address - Phone:763-389-3344
Mailing Address - Fax:763-389-6221
Practice Address - Street 1:919 NORTHLAND DR
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:MN
Practice Address - Zip Code:55371-2172
Practice Address - Country:US
Practice Address - Phone:763-389-3344
Practice Address - Fax:763-389-6221
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-06
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN49834207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine