Provider Demographics
NPI:1902913304
Name:PETERSON, DANIEL A (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:A
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-647-6326
Mailing Address - Fax:414-671-8860
Practice Address - Street 1:2414 KOHLER MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081
Practice Address - Country:US
Practice Address - Phone:920-457-4461
Practice Address - Fax:920-459-1412
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI398162085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32434300Medicaid
BP5879020OtherDEA NUMBER
600400143Medicare ID - Type UnspecifiedMEDICARE PROVIDER
G70365Medicare UPIN