Healthcare Provider Details

I. General information

NPI: 1235181611
Provider Name (Legal Business Name): LOWELL FRANK PETERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 10/03/2014
Certification Date:
Deactivation Date: 09/24/2009
Reactivation Date: 09/17/2014

III. Provider practice location address

2627 BEECHWOOD COURT
APPLETON WI
54911
US

IV. Provider business mailing address

2627 BEECHWOOD COURT
APPLETON WI
54911
US

V. Phone/Fax

Practice location:
  • Phone: 920-739-8004
  • Fax: 920-225-1479
Mailing address:
  • Phone: 920-739-8004
  • Fax: 920-225-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number14668-20
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number14668-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: