Basic Information
| Provider Information | |||||||||
| NPI: | 1124005822 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 9TH ST SE | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559046756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5072883443 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 210 9TH ST SE | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559046756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5072883443 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2005 | ||||||||
| LastUpdateDate: | 03/13/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 44050 | MN | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 44T5PE | 05 | MN | MEDICAID | 969670900 | 05 | MN | MEDICAID | 577577 | 05 | IA | MEDICAID | MH9041041407 | 01 | MN | PREFERREDONE | OTHER | 141091 | 05 | MN | MEDICAID | 08-01109 | 01 | MN | MEDICA | OTHER | 2159678 | 01 | MN | ARAZ | OTHER | 9898 | 01 | MN | AVERA | OTHER | HP42865 | 01 | MN | HEALTHPARTNERS | OTHER | 444T5PE | 01 | MN | BLUE CROSS | OTHER |