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General NPI Number Information
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NPI Number | 1164041505
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Entity Type | Individual
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Provider Name | MATTHEW JON PETERSON MD
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Gender | Male
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Dates
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Enumeration Date | 04/15/2020
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Last Update Date | 08/29/2025
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Provider Practice Location Address
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Address Line | 111 17TH AVE E
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City | ALEXANDRIA
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State | MN
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Zip | 56308-5273
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Country | US
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Telephone | 320-763-2707
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Fax | 320-763-7883
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Provider Business Mailing Address
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Address Line | 610 30TH AVE W
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City | ALEXANDRIA
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State | MN
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Zip | 56308-3426
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Country | US
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Telephone | 320-763-2540
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Fax | 320-763-5749
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number | 79148
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License Number State | MN
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