Healthcare Provider Details

I. General information

NPI: 1710962832
Provider Name (Legal Business Name): DOUGLAS PETERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 ANDERSON AVE
BUFFALO MN
55313-2945
US

IV. Provider business mailing address

5008 QUEEN AVE S
MINNEAPOLIS MN
55410-2207
US

V. Phone/Fax

Practice location:
  • Phone: 800-876-7171
  • Fax:
Mailing address:
  • Phone: 612-929-0298
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number22930
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: