Provider Demographics
NPI:1124005822
Name:PETERSON, DANIEL (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
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 1:210 9TH ST SE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55904-6756
Mailing Address - Country:US
Mailing Address - Phone:507-288-3443
Mailing Address - Fax:
Practice Address - Street 1:210 9TH ST SE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55904-6756
Practice Address - Country:US
Practice Address - Phone:507-288-3443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN44050207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN44T5PEMedicaid
MN969670900Medicaid
IA577577Medicaid
MNMH9041041407OtherPREFERREDONE
MN141091Medicaid
MN08-01109OtherMEDICA
MN2159678OtherARAZ
MN9898OtherAVERA
MNHP42865OtherHEALTHPARTNERS
MN444T5PEOtherBLUE CROSS
MN2159678OtherARAZ
H40198Medicare UPIN
MN969670900Medicaid
MN141091Medicaid