Provider Demographics
NPI:1740420660
Name:PETERSON, KARL GREGORY (MD)
Entity Type:Individual
Prefix:DR
First Name:KARL
Middle Name:GREGORY
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 1:3013 W SPRUCELEIGH CT
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-0170
Mailing Address - Country:US
Mailing Address - Phone:605-338-5333
Mailing Address - Fax:
Practice Address - Street 1:3013 W SPRUCELEIGH CT
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-0170
Practice Address - Country:US
Practice Address - Phone:605-338-5333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-05
Last Update Date:2009-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1228207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDD25542OtherUPIN