Provider Demographics
NPI:1235109430
Name:PETERSON, RANDY J (MD)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:J
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 1:1527 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-2537
Mailing Address - Country:US
Mailing Address - Phone:320-762-0399
Mailing Address - Fax:320-762-6847
Practice Address - Street 1:1527 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-2537
Practice Address - Country:US
Practice Address - Phone:320-762-0399
Practice Address - Fax:320-762-6847
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN32212174400000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN107120D277OtherUCARE
MN33Y08PEOtherBLUE SHIELD
MNHP27225OtherHEALTH PARTNERS
MN0104802OtherMEDICA
MN1006215OtherPREFERRED ONE
MN687892000Medicaid
MNA006OtherCHAMPUS
MN21468OtherAMERICA'S PPO
MN107120D277OtherUCARE
MN687892000Medicaid