Provider Demographics
NPI:1831541812
Name:PETERSON, GARY DANIEL (DO)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:DANIEL
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:DANNY
Other - Middle Name:
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:1650 4TH ST SE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55904-4717
Mailing Address - Country:US
Mailing Address - Phone:507-529-6600
Mailing Address - Fax:
Practice Address - Street 1:1650 4TH ST SE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55904-4717
Practice Address - Country:US
Practice Address - Phone:507-529-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-01
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020013851207L00000X
MO2016022176207L00000X
MN74496207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology