Provider Demographics
NPI:1033585161
Name:PETERSON, CASEY MICHELLE (OD)
Entity Type:Individual
Prefix:DR
First Name:CASEY
Middle Name:MICHELLE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 UNIVERSITY BLVD
Mailing Address - Street 2:PATIENT CARE CENTER
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63121-4400
Mailing Address - Country:US
Mailing Address - Phone:314-516-5131
Mailing Address - Fax:314-516-5507
Practice Address - Street 1:7840 NATURAL BRIDGE BLVD
Practice Address - Street 2:1 UNIVERSITY BLVD
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63121-4617
Practice Address - Country:US
Practice Address - Phone:314-516-5131
Practice Address - Fax:314-516-5507
Is Sole Proprietor?:No
Enumeration Date:2015-08-12
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016029774152W00000X
IL046011064152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1033585161Medicaid
IL046011064Medicaid
ILF400321217Medicare PIN
MO067820050Medicare PIN
MO074730051Medicare PIN