Provider Demographics
NPI:1225050891
Name:PETERSEN, WILLIAM M (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:M
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:WALKER
Mailing Address - State:MN
Mailing Address - Zip Code:56484-1390
Mailing Address - Country:US
Mailing Address - Phone:218-547-3938
Mailing Address - Fax:218-547-3922
Practice Address - Street 1:614 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:WALKER
Practice Address - State:MN
Practice Address - Zip Code:56484-1390
Practice Address - Country:US
Practice Address - Phone:218-547-3938
Practice Address - Fax:218-547-3922
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN29875207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E07136Medicare UPIN