Healthcare Provider Details

I. General information

NPI: 1528276912
Provider Name (Legal Business Name): DANIEL ALBIN PETERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 12/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N WOLFE ST ROSS 659
BALTIMORE MD
21287-0005
US

IV. Provider business mailing address

PO BOX 64478
BALTIMORE MD
21264-4478
US

V. Phone/Fax

Practice location:
  • Phone: 443-287-4593
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberD72729
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number200301074
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: