Provider Demographics
NPI:1326148933
Name:PETERSMA, JAY D (OD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:D
Last Name:PETERSMA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5501 NW 86TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:JOHNSTON
Mailing Address - State:IA
Mailing Address - Zip Code:50131-1816
Mailing Address - Country:US
Mailing Address - Phone:515-270-0494
Mailing Address - Fax:515-270-6463
Practice Address - Street 1:5501 NW 86TH ST
Practice Address - Street 2:SUITE 500
Practice Address - City:JOHNSTON
Practice Address - State:IA
Practice Address - Zip Code:50131-1816
Practice Address - Country:US
Practice Address - Phone:515-270-0494
Practice Address - Fax:515-270-6463
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-24
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01861152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA18665OtherMIDLANDS CHOICE
IA26387OtherWELLMARK
IA18665OtherMIDLANDS CHOICE
IAT01492Medicare UPIN