Provider Demographics
NPI:1164411930
Name:PETERSON, DAVID JAMES (OD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:JAMES
Last Name:PETERSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 MINNIE ST
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-3006
Mailing Address - Country:US
Mailing Address - Phone:907-456-7760
Mailing Address - Fax:907-328-1867
Practice Address - Street 1:116 MINNIE ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-3006
Practice Address - Country:US
Practice Address - Phone:907-456-7760
Practice Address - Fax:907-328-1867
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2496152W00000X
AK358152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist