Basic Information
| Provider Information | |||||||||
| NPI: | 1689751885 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | JOSEPH | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 505 STATE STREET | ||||||||
| Address2: | |||||||||
| City: | TRACY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 561751539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076293230 | ||||||||
| FaxNumber: | 5076293230 | ||||||||
| Practice Location | |||||||||
| Address1: | 505 STATE STREET | ||||||||
| Address2: | |||||||||
| City: | TRACY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 561751539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076293230 | ||||||||
| FaxNumber: | 5076293230 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 04/29/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2056 | MN | Y | Eye and Vision Services Providers | Optometrist | 152W00000X | 2101 | WI | N | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 3C276PB | 01 | MN | BLUE PLUS | OTHER | 410011573 | 01 | MN | MEDICARE RAILROAD | OTHER | 697823100 | 05 | MN | MEDICAID | 898861020124 | 01 | MN | PREFERRED CHOICES | OTHER | 112984 | 01 | MN | UCARE | OTHER | 43233PB | 01 | MN | BCBS | OTHER |