Provider Demographics
NPI:1407833973
Name:PETERSON, DANIEL P (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:P
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 1:360 BARD AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10310-1666
Mailing Address - Country:US
Mailing Address - Phone:718-876-2000
Mailing Address - Fax:718-876-2006
Practice Address - Street 1:360 BARD AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10310-1666
Practice Address - Country:US
Practice Address - Phone:718-876-2000
Practice Address - Fax:718-876-2006
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1926432085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01542209Medicaid
NY66J031Medicare ID - Type Unspecified
NY01542209Medicaid