Provider Demographics
NPI:1194714097
Name:WALDUSKY, PETER WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:WILLIAM
Last Name:WALDUSKY
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 1:1200 SIXTH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2735
Mailing Address - Country:US
Mailing Address - Phone:320-251-2700
Mailing Address - Fax:320-240-2118
Practice Address - Street 1:1200 SIXTH AVE N
Practice Address - Street 2:
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2735
Practice Address - Country:US
Practice Address - Phone:320-251-2700
Practice Address - Fax:320-240-2118
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN44863207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1031038OtherPREFERRED ONE
MN315339800Medicaid
0404593OtherMEDICA HEALTH PLANS
141884OtherU-CARE
HP35324OtherHEALTH PARTNERS
1628854OtherARAZ GROUP/AMERICA'S PPO
2113976OtherFIRST HEALTH PLAN
315339800OtherMEDICAL ASSISTANCE
60G47WAOtherBLUE CROSS BLUE SHIELD
315339800OtherMEDICAL ASSISTANCE
141884OtherU-CARE