Provider Demographics
NPI:1962434951
Name:PETERSON, BRIAN LEE (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:LEE
Last Name:PETERSON
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 1:933 W HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53233-1445
Mailing Address - Country:US
Mailing Address - Phone:414-223-1216
Mailing Address - Fax:414-223-1237
Practice Address - Street 1:933 W HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233-1445
Practice Address - Country:US
Practice Address - Phone:414-223-1216
Practice Address - Fax:414-223-1237
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG48918207ZF0201X
WI49701-20207ZF0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZF0201XAllopathic & Osteopathic PhysiciansPathologyForensic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E67881Medicare UPIN