Provider Demographics
NPI:1508832676
Name:PETERSON, JON DAVID (DPM)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:DAVID
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49725 COUNTY 83
Mailing Address - Street 2:
Mailing Address - City:STAPLES
Mailing Address - State:MN
Mailing Address - Zip Code:56479-5280
Mailing Address - Country:US
Mailing Address - Phone:218-894-1515
Mailing Address - Fax:218-894-8767
Practice Address - Street 1:49725 COUNTY 83
Practice Address - Street 2:
Practice Address - City:STAPLES
Practice Address - State:MN
Practice Address - Zip Code:56479-5280
Practice Address - Country:US
Practice Address - Phone:218-894-1515
Practice Address - Fax:218-894-8767
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN513213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN513OtherMN LICENSE