Provider Demographics
NPI:1437451440
Name:PEDERSON, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:PEDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4551 S WASHINGTON ST STE H
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-3495
Mailing Address - Country:US
Mailing Address - Phone:218-791-6424
Mailing Address - Fax:
Practice Address - Street 1:4551 S WASHINGTON ST STE H
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-3495
Practice Address - Country:US
Practice Address - Phone:218-791-6424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-23
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician