Basic Information
| Provider Information | |||||||||
| NPI: | 1760454946 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2019 JEFFERSON RD | ||||||||
| Address2: | STE A | ||||||||
| City: | NORTHFIELD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550573258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076459202 | ||||||||
| FaxNumber: | 5076459203 | ||||||||
| Practice Location | |||||||||
| Address1: | 8600 NICOLLET AVE S | ||||||||
| Address2: | MAIL STOP 31500A | ||||||||
| City: | BLOOMINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554202824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528876600 | ||||||||
| FaxNumber: | 9528867015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2006 | ||||||||
| LastUpdateDate: | 04/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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| NPICertificationDate: | 04/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2567 | MN | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 989014900 | 05 | MN | MEDICAID |