Provider Demographics
NPI:1386834984
Name:PETERSON, EARL JOEL (MD)
Entity Type:Individual
Prefix:DR
First Name:EARL
Middle Name:JOEL
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:4080 W BROADWAY AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ROBBINSDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55422-5604
Mailing Address - Country:US
Mailing Address - Phone:763-520-5551
Mailing Address - Fax:763-520-1734
Practice Address - Street 1:4080 W BROADWAY AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422-5604
Practice Address - Country:US
Practice Address - Phone:763-520-5551
Practice Address - Fax:763-520-1734
Is Sole Proprietor?:No
Enumeration Date:2007-07-30
Last Update Date:2007-10-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN25889207Q00000X, 2083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine