Provider Demographics
NPI:1194039248
Name:PETERSEN, ERIN KAY (OD)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:KAY
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 1:1600 MILLER TRUNK HWY
Mailing Address - Street 2:SUITE 429
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811-5640
Mailing Address - Country:US
Mailing Address - Phone:218-727-5457
Mailing Address - Fax:218-740-3094
Practice Address - Street 1:1600 MILLER TRUNK HWY
Practice Address - Street 2:SUITE 429
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811-5640
Practice Address - Country:US
Practice Address - Phone:218-727-5457
Practice Address - Fax:218-740-3094
Is Sole Proprietor?:No
Enumeration Date:2010-07-31
Last Update Date:2010-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3205152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist