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General NPI Number Information
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NPI Number | 1710962832
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Entity Type | Individual
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Provider Name | DOUGLAS PETERSON M.D.
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Gender | Male
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Dates
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Enumeration Date | 12/13/2005
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Last Update Date | 07/09/2007
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Provider Practice Location Address
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Address Line | 1630 ANDERSON AVE
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City | BUFFALO
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State | MN
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Zip | 55313-2945
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Country | US
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Telephone | 800-876-7171
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Fax |
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Provider Business Mailing Address
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Address Line | 5008 QUEEN AVE S
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City | MINNEAPOLIS
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State | MN
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Zip | 55410-2207
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Country | US
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Telephone | 612-929-0298
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Fax |
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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 | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | 22930
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License Number State | MN
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