Provider Demographics
NPI:1205807831
Name:PETERS, DAVID KELLOGG (MD, PHD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:KELLOGG
Last Name:PETERS
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 44159
Mailing Address - Street 2:WPSC-SVA BILLING
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53744-4159
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:36 S BROOKS ST
Practice Address - Street 2:WISCONSIN PATHOLOGISTS, SC
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1304
Practice Address - Country:US
Practice Address - Phone:608-826-2663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI39132-020207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI327-02900Medicaid
WI327-02900Medicaid