Provider Demographics
NPI:1790905669
Name:PETERSON, MARIE ELIZABETH (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIE
Middle Name:ELIZABETH
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARIE
Other - Middle Name:ELIZABETH
Other - Last Name:REICHLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1021 BANDANA BLVD E
Mailing Address - Street 2:SUITE 121
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-5113
Mailing Address - Country:US
Mailing Address - Phone:651-241-3959
Mailing Address - Fax:
Practice Address - Street 1:2925 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-1321
Practice Address - Country:US
Practice Address - Phone:612-262-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN53826207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN070000930Medicare PIN