Healthcare Provider Details

I. General information

NPI: 1962434951
Provider Name (Legal Business Name): BRIAN LEE PETERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 07/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

933 W HIGHLAND AVE
MILWAUKEE WI
53233-1445
US

IV. Provider business mailing address

933 W HIGHLAND AVE
MILWAUKEE WI
53233-1445
US

V. Phone/Fax

Practice location:
  • Phone: 414-223-1216
  • Fax: 414-223-1237
Mailing address:
  • Phone: 414-223-1216
  • Fax: 414-223-1237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZF0201X
TaxonomyForensic Pathology Physician
License NumberG48918
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207ZF0201X
TaxonomyForensic Pathology Physician
License Number49701-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: