Provider Demographics
NPI:1790844009
Name:PETERSON, GREGORY JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:JAMES
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1505 PEBBLE LAKE RD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:FERGUS FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56537-3800
Mailing Address - Country:US
Mailing Address - Phone:218-736-1884
Mailing Address - Fax:218-736-1880
Practice Address - Street 1:1505 PEBBLE LAKE RD
Practice Address - Street 2:SUITE 500
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-3800
Practice Address - Country:US
Practice Address - Phone:218-736-1884
Practice Address - Fax:218-736-1880
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN020301207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN436777400Medicaid
MN436777400Medicaid