Provider Demographics
NPI:1710962832
Name:PETERSON, DOUGLAS (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
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 1:5008 QUEEN AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55410-2207
Mailing Address - Country:US
Mailing Address - Phone:612-929-0298
Mailing Address - Fax:
Practice Address - Street 1:1630 ANDERSON AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313-2945
Practice Address - Country:US
Practice Address - Phone:800-876-7171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN22930207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN92M48PEOtherBCBS
MN92M48PEMedicaid
MN146290300Medicaid
MN92M48PEMedicaid