Provider Demographics
NPI:1164594537
Name:PETERSON, DONALD CARL (DC)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:CARL
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 1:2516 7TH AVE E
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55109-3003
Mailing Address - Country:US
Mailing Address - Phone:651-770-3805
Mailing Address - Fax:651-747-8737
Practice Address - Street 1:2516 7TH AVE E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55109-3003
Practice Address - Country:US
Practice Address - Phone:651-770-3805
Practice Address - Fax:651-747-8737
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1160111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor