Provider Demographics
NPI:1215971627
Name:PETERSON, DAVID ARTHUR (PT)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:ARTHUR
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W66N764 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:CEDARBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53012-1151
Mailing Address - Country:US
Mailing Address - Phone:262-376-9175
Mailing Address - Fax:
Practice Address - Street 1:1317 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:WI
Practice Address - Zip Code:53074-2075
Practice Address - Country:US
Practice Address - Phone:262-284-2261
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3553225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist