Provider Demographics
NPI:1013965755
Name:PETERS, CHARLES (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:PETERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1510
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54702-1510
Mailing Address - Country:US
Mailing Address - Phone:608-785-0940
Mailing Address - Fax:
Practice Address - Street 1:191 THEATER ROAD
Practice Address - Street 2:MAYO CLINIC HEALTH SYSTEM FRANCISCAN HEALTHCARE
Practice Address - City:ONALASKA
Practice Address - State:WI
Practice Address - Zip Code:54650-8679
Practice Address - Country:US
Practice Address - Phone:608-392-5002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI570302080P0207X
MO20050293132080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207460007Medicaid
KS100329500BMedicaid
KS100329500BMedicaid