Provider Demographics
NPI:1497973630
Name:PETERSEN, JOHN ROBERT (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ROBERT
Last Name:PETERSEN
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 1:2216 COUNTY ROAD D W
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55112-7500
Mailing Address - Country:US
Mailing Address - Phone:651-639-1066
Mailing Address - Fax:651-639-1069
Practice Address - Street 1:2216 COUNTY ROAD D W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55112-7500
Practice Address - Country:US
Practice Address - Phone:651-639-1066
Practice Address - Fax:651-639-1069
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4232111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN411508205OtherHSM PREFERRED ONE
MN65M40PEOtherBLUE CROSS BLUE SHIELD
MN906459100Medicaid
MN350003037Medicare ID - Type Unspecified
MN906459100Medicaid