Provider Demographics
NPI:1376536813
Name:PETTERBORG, PHILLIP WARREN (OD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:WARREN
Last Name:PETTERBORG
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 1:906 E PEBWORTH RD
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:DE
Mailing Address - Zip Code:19962-1848
Mailing Address - Country:US
Mailing Address - Phone:302-697-6176
Mailing Address - Fax:302-677-2525
Practice Address - Street 1:300 TUSKEGEE BLVD
Practice Address - Street 2:
Practice Address - City:DOVER AFB
Practice Address - State:DE
Practice Address - Zip Code:19902-5300
Practice Address - Country:US
Practice Address - Phone:302-677-2574
Practice Address - Fax:302-677-2526
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-730152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist