Healthcare Provider Details

I. General information

NPI: 1780760868
Provider Name (Legal Business Name): DAVID C PETERSON DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 01/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 S MINNESOTA ST
CROOKSTON MN
56716-1601
US

IV. Provider business mailing address

11823 MAPLE LAKE DR SE
MENTOR MN
56736-9443
US

V. Phone/Fax

Practice location:
  • Phone: 218-281-9556
  • Fax:
Mailing address:
  • Phone: 218-574-2220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number301
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number301
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: