Provider Demographics
NPI:1699717561
Name:PETERSON, RICHARD ALVIN (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:ALVIN
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S # MS 21110Q
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:640 JACKSON ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-2502
Practice Address - Country:US
Practice Address - Phone:651-254-3448
Practice Address - Fax:763-302-4081
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN475562084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNHP51315OtherHEALTHPARTNERS
MN2350907OtherAAMERICA'S PPO
MN01N64PEOtherBCBS OF MN
MNP00225563OtherRAILROAD MEDICARE
MN236934600Medicaid
MN0500505OtherMEDICA
MN1043493OtherPREFERRED ONE
WI34640200Medicaid
MN132846C029OtherUCARE
MN2350907OtherAAMERICA'S PPO
MN132846C029OtherUCARE