Provider Demographics
NPI:1376514372
Name:PETERS, DAVID L (OD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:L
Last Name:PETERS
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 1:611 W STATE ST
Mailing Address - Street 2:P.O.BOX 204
Mailing Address - City:SAINT JOHNS
Mailing Address - State:MI
Mailing Address - Zip Code:48879-1451
Mailing Address - Country:US
Mailing Address - Phone:989-224-6651
Mailing Address - Fax:989-224-7024
Practice Address - Street 1:611 W STATE ST
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:MI
Practice Address - Zip Code:48879-1451
Practice Address - Country:US
Practice Address - Phone:989-224-6651
Practice Address - Fax:989-224-7024
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-28
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI002404152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIA96503001Medicare PIN
MIT32695Medicare UPIN
MI1376514372Medicare NSC