Provider Demographics
NPI:1285863530
Name:PETERSON, DANE M (OD)
Entity Type:Individual
Prefix:DR
First Name:DANE
Middle Name:M
Last Name:PETERSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:8401 GOLDEN VALLEY RD STE 330
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55427-4488
Mailing Address - Country:US
Mailing Address - Phone:763-416-7629
Mailing Address - Fax:763-383-4147
Practice Address - Street 1:2601 39TH AVE NE STE 1
Practice Address - Street 2:
Practice Address - City:ST. ANTHONY
Practice Address - State:MN
Practice Address - Zip Code:55421-4372
Practice Address - Country:US
Practice Address - Phone:763-416-7600
Practice Address - Fax:763-416-7634
Is Sole Proprietor?:No
Enumeration Date:2009-07-08
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2738152W00000X
MN3325152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOA106590Medicare PIN