Provider Demographics
NPI:1811188741
Name:PETERSON, SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
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 1:212 N PRAIRIE ST
Mailing Address - Street 2:
Mailing Address - City:FLANDREAU
Mailing Address - State:SD
Mailing Address - Zip Code:57028-1243
Mailing Address - Country:US
Mailing Address - Phone:605-997-2471
Mailing Address - Fax:605-997-2418
Practice Address - Street 1:212 N PRAIRIE ST
Practice Address - Street 2:
Practice Address - City:FLANDREAU
Practice Address - State:SD
Practice Address - Zip Code:57028-1243
Practice Address - Country:US
Practice Address - Phone:605-997-2471
Practice Address - Fax:605-997-2418
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2011-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD7864207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
433429Medicare Oscar/Certification
SDS40004Medicare PIN
SDS104188Medicare PIN