Provider Demographics
NPI:1679561070
Name:PETERSON, JOSEPH ROGER (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:ROGER
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 1:400 WATER AVE
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:WI
Mailing Address - Zip Code:54634-9054
Mailing Address - Country:US
Mailing Address - Phone:608-489-8000
Mailing Address - Fax:
Practice Address - Street 1:400 WATER AVE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:WI
Practice Address - Zip Code:54634-9054
Practice Address - Country:US
Practice Address - Phone:608-489-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL5092207N00000X
WI55789207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH81642Medicare UPIN
TX8A5609Medicare PIN