Active NPI
Roger Dwight Petersen, M.D.
- Family Medicine Physician
- Elkhorn, WI
National Provider Identifier
1871853846
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- License
- 15694-20
- Practice address
- 20 South Washington St
Elkhorn, WI 53121 - Phone
- (262) 723-6668
- NPI assigned
- May 23, 2012
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | 15694-20 | WI | Primary |
Addresses
Primary practice location
20 South Washington St
Elkhorn, WI 53121
Mailing address
5197 Majorca Club Drive
Boca Raton, FL 33486
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 15694-20 | WI | MD | Family Medicine Physician |
| 24117 | FL | MD | Occupational Therapist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1337731200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1337731200000",
"number": "1871853846",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "5197 MAJORCA CLUB DRIVE",
"city": "BOCA RATON",
"state": "FL",
"postal_code": "33486"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "20 SOUTH WASHINGTON ST",
"city": "ELKHORN",
"state": "WI",
"postal_code": "53121",
"telephone_number": "262-723-6668"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PETERSEN",
"first_name": "ROGER",
"middle_name": "DWIGHT",
"name_prefix": "Dr.",
"credential": "M.D.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2012-05-23",
"last_updated": "2012-05-23",
"status": "A"
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "",
"desc": "Family Medicine",
"state": "WI",
"license": "15694-20",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Elkhorn, WI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 23, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.