Basic Information
| Provider Information | |||||||||
| NPI: | 1992793806 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEDERSEN | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | PAUL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PEDERSEN | ||||||||
| OtherFirstName: | ERIC | ||||||||
| OtherMiddleName: | PAUL | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | SR. | ||||||||
| OtherCredential: | OD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 120 MARTIN DR | ||||||||
| Address2: | |||||||||
| City: | FREDONIA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530219455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626929000 | ||||||||
| FaxNumber: | 2626922797 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 MARTIN DR | ||||||||
| Address2: | |||||||||
| City: | FREDONIA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530219455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626929000 | ||||||||
| FaxNumber: | 2626922797 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2005 | ||||||||
| LastUpdateDate: | 02/22/2013 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2745 | WI | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.