Provider Demographics
NPI:1023406493
Name:PETERSON DERMATOLOGY, S.C.
Entity type:Organization
Organization Name:PETERSON DERMATOLOGY, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DERMATOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:S
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:608-574-5044
Mailing Address - Street 1:1204 JOSEPH ST # 2
Mailing Address - Street 2:
Mailing Address - City:DODGEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53533-9670
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1204 JOSEPH ST # 2
Practice Address - Street 2:
Practice Address - City:DODGEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53533-9670
Practice Address - Country:US
Practice Address - Phone:608-574-5044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-07
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty