Provider Demographics
NPI:1780768937
Name:PETERSON, BRUCE A (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:A
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:UNIVERSITY OF MINNESOTA PHYSICIANS
Mailing Address - Street 2:420 DELAWARE STREET SE
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455
Mailing Address - Country:US
Mailing Address - Phone:612-625-5411
Mailing Address - Fax:
Practice Address - Street 1:UNIVERSITY OF MINNESOTA PHYSICIANS
Practice Address - Street 2:420 DELAWARE STREET SE
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455
Practice Address - Country:US
Practice Address - Phone:612-625-5411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN20660207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1009270OtherPREFERRED ONE
MN768301OtherARAZ
MN36-00273OtherMEDICA PRIMARY
MN36-24612OtherMEDICA CHOICE
MNHP22238OtherHEALTH PARTNERS
MN100798OtherUCARE
MN2T174PEOtherBLUE CROSS BLUE SHIELD
MN990868400Medicaid
MN768301OtherARAZ
A95906Medicare UPIN
MN990868400Medicaid