Provider Demographics
NPI:1689712101
Name:PETER, TODD MICHAEL (DC)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:MICHAEL
Last Name:PETER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4937 SYCAMORE DRIVE
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55123
Mailing Address - Country:US
Mailing Address - Phone:651-322-7446
Mailing Address - Fax:
Practice Address - Street 1:750 HIGHWAY 110
Practice Address - Street 2:STE 13
Practice Address - City:MENDOTA HGTS
Practice Address - State:MN
Practice Address - Zip Code:55120
Practice Address - Country:US
Practice Address - Phone:651-452-8333
Practice Address - Fax:651-452-0387
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2801111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
231512OtherCHIRO CARE OF MN
392LOPEOtherBCBS CLINIC NO
392LIPEOtherBCBS PERSONAL NO