Provider Demographics
NPI:1992190003
Name:PETERSON, DANIEL W
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:W
Last Name:PETERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8900 SPRING GRV N
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36695-5327
Mailing Address - Country:US
Mailing Address - Phone:251-604-2152
Mailing Address - Fax:
Practice Address - Street 1:620 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3923
Practice Address - Country:US
Practice Address - Phone:731-541-6026
Practice Address - Fax:731-541-7958
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-06
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN60752207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program