Provider Demographics
NPI:1639229255
Name:PETERSON, JEFFERY LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFERY
Middle Name:LEE
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 1:1027 LAWRENCE CIR
Mailing Address - Street 2:
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-2081
Mailing Address - Country:US
Mailing Address - Phone:605-997-2642
Mailing Address - Fax:605-997-9940
Practice Address - Street 1:701 W BROAD AVE
Practice Address - Street 2:
Practice Address - City:FLANDREAU
Practice Address - State:SD
Practice Address - Zip Code:57028-1529
Practice Address - Country:US
Practice Address - Phone:605-997-2642
Practice Address - Fax:605-997-9940
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1067207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5546010Medicaid
MND25540Medicare UPIN