Provider Demographics
NPI:1043569858
Name:PETERSEN, BALEY (OD)
Entity Type:Individual
Prefix:DR
First Name:BALEY
Middle Name:
Last Name:PETERSEN
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 1:1481 CENTER STREET EXT APT 1001
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-4674
Mailing Address - Country:US
Mailing Address - Phone:712-229-1508
Mailing Address - Fax:
Practice Address - Street 1:966 HOUSTON NORTHCUTT BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3487
Practice Address - Country:US
Practice Address - Phone:843-881-2492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-07
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1741152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist