Provider Demographics
NPI:1477551836
Name:PETERSON, MARK DEAN (DC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DEAN
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5406 ALDERSON ST
Mailing Address - Street 2:
Mailing Address - City:SCHOFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54476-2264
Mailing Address - Country:US
Mailing Address - Phone:715-359-3399
Mailing Address - Fax:
Practice Address - Street 1:5406 ALDERSON ST
Practice Address - Street 2:
Practice Address - City:SCHOFIELD
Practice Address - State:WI
Practice Address - Zip Code:54476-2264
Practice Address - Country:US
Practice Address - Phone:715-359-3399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2227111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIT79162Medicare UPIN
WI75939Medicare ID - Type Unspecified