Provider Demographics
NPI:1497852040
Name:PETERSON, CHRISTINE RENNAE (OD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTINE
Middle Name:RENNAE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1363 GRANDVIEW CT
Mailing Address - Street 2:
Mailing Address - City:MINNESOTA CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55959-1209
Mailing Address - Country:US
Mailing Address - Phone:507-494-0042
Mailing Address - Fax:
Practice Address - Street 1:1213 GILMORE AVE
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MN
Practice Address - Zip Code:55987-2474
Practice Address - Country:US
Practice Address - Phone:507-454-1792
Practice Address - Fax:507-454-1793
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN 2563152W00000X
WI2885 - 035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN52P81PEOtherBCBS
MN2202971OtherMEDICA
MN2202971OtherMEDICA