Provider Demographics
NPI:1235181611
Name:PETERSON, LOWELL FRANK (MD)
Entity Type:Individual
Prefix:MR
First Name:LOWELL
Middle Name:FRANK
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 1:2627 BEECHWOOD COURT
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911
Mailing Address - Country:US
Mailing Address - Phone:920-739-8004
Mailing Address - Fax:920-225-1479
Practice Address - Street 1:2627 BEECHWOOD COURT
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911
Practice Address - Country:US
Practice Address - Phone:920-739-8004
Practice Address - Fax:920-225-1479
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2014-10-03
Deactivation Date:2009-09-24
Deactivation Code:
Reactivation Date:2014-09-17
Provider Licenses
StateLicense IDTaxonomies
WI14668-20207RC0000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31153400Medicaid
WI31153400Medicaid
WI0004Medicare ID - Type Unspecified