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General NPI Number Information
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NPI Number | 1780760868
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Entity Type | Individual
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Provider Name | DAVID C PETERSON DPM
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Gender | Male
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Dates
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Enumeration Date | 10/31/2006
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Last Update Date | 01/08/2008
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Provider Practice Location Address
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Address Line | 323 S MINNESOTA ST
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City | CROOKSTON
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State | MN
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Zip | 56716-1601
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Country | US
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Telephone | 218-281-9556
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Fax |
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Provider Business Mailing Address
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Address Line | 11823 MAPLE LAKE DR SE
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City | MENTOR
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State | MN
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Zip | 56736-9443
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Country | US
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Telephone | 218-574-2220
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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 | 213EP1101X
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Taxonomy Name | Primary Podiatric Medicine Podiatrist
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License Number | 301
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 213ES0131X
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Taxonomy Name | Foot Surgery Podiatrist
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License Number | 301
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License Number State | MN
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