Basic Information
| Provider Information | |||||||||
| NPI: | 1134163850 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3200 E RACINE ST | ||||||||
| Address2: | |||||||||
| City: | JANESVILLE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535462343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083718000 | ||||||||
| FaxNumber: | 6083718942 | ||||||||
| Practice Location | |||||||||
| Address1: | 3200 E RACINE ST | ||||||||
| Address2: | |||||||||
| City: | JANESVILLE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535462343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083718000 | ||||||||
| FaxNumber: | 6083718942 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 11/30/2013 | ||||||||
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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 | 207RC0000X | 21306-020 | WI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207R00000X | 21306-020 | WI | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 30127100 | 05 | WI | MEDICAID | 1042 | 01 | WI | DEAN HEALTH INSURANCE | OTHER |