Provider Demographics
NPI:1104821362
Name:PETERSON, DONALD ALBERT (DC)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:ALBERT
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:835 HIGHWAY 105
Mailing Address - Street 2:SUITE A
Mailing Address - City:PALMER LAKE
Mailing Address - State:CO
Mailing Address - Zip Code:80133-9069
Mailing Address - Country:US
Mailing Address - Phone:719-332-6201
Mailing Address - Fax:
Practice Address - Street 1:835 HIGHWAY 105
Practice Address - Street 2:SUITE A
Practice Address - City:PALMER LAKE
Practice Address - State:CO
Practice Address - Zip Code:80133-9069
Practice Address - Country:US
Practice Address - Phone:719-332-6201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2012-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5463111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO505318Medicare ID - Type Unspecified