Provider Demographics
NPI:1619051869
Name:PETERSON, ERIK JON (MD)
Entity Type:Individual
Prefix:
First Name:ERIK
Middle Name:JON
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:UNIVERSITY OF MINNESOTA PHYSICIANS
Mailing Address - Street 2:420 DELAWARE STREET SE
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455
Mailing Address - Country:US
Mailing Address - Phone:612-625-8690
Mailing Address - Fax:
Practice Address - Street 1:516 DELAWARE ST SE
Practice Address - Street 2:PWB SIXTH FLOOR, CLINIC 6A
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0356
Practice Address - Country:US
Practice Address - Phone:612-625-8690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN45093207R00000X, 207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN32-00003OtherMEDICA PRIMARY
MN32-00093OtherMEDICA CHOICE
MNHP39455OtherHEALTH PARTNERS
MN090883500Medicaid
MN244A6PEOtherBLUE CROSS BLUE SHIELD
MN1686374OtherARAZ
MN1031720OtherPREFERRED ONE
MN142412OtherUCARE
WI34260300Medicaid
MN32-00093OtherMEDICA CHOICE