Provider Demographics
NPI:1629127915
Name:PETERSON, STEPHEN P (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:P
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 1:501 PHEASANT RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:WI
Mailing Address - Zip Code:53125-1491
Mailing Address - Country:US
Mailing Address - Phone:262-275-5663
Mailing Address - Fax:
Practice Address - Street 1:146 E GENEVA SQ
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-9694
Practice Address - Country:US
Practice Address - Phone:262-249-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI45762207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34399700Medicaid
WI34399700Medicaid