Provider Demographics
NPI:1508885013
Name:PETERSON, DENNIS L (MD)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:L
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 1:1555 NORTHWAY DRIVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-4913
Mailing Address - Country:US
Mailing Address - Phone:320-240-3157
Mailing Address - Fax:320-240-3143
Practice Address - Street 1:1555 NORTHWAY DRIVE
Practice Address - Street 2:SUITE 200
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-4913
Practice Address - Country:US
Practice Address - Phone:320-240-3157
Practice Address - Fax:320-240-3143
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN33856207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN01-25185OtherMEDICA
MN2F977PEOtherBLUE CROSS BLUE SHIELD
MN080049494OtherRR MEDICARE
MN118202100Medicaid
MN325101845OtherPRIMEWEST
MN764610OtherARAZ
MNHP21681OtherHEALTH PARTNERS
MN114462OtherUCARE
MNMR1081007925OtherPREFERRED ONE
MN089002732Medicare ID - Type Unspecified
MN118202100Medicaid