Provider Demographics
NPI:1578691820
Name:PETERSON, BRUCE B (OD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:B
Last Name:PETERSON
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 1:1211 LAUREL LN
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60193-4736
Mailing Address - Country:US
Mailing Address - Phone:847-524-2225
Mailing Address - Fax:
Practice Address - Street 1:1134 S ROSELLE RD
Practice Address - Street 2:
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60193-4072
Practice Address - Country:US
Practice Address - Phone:847-524-7771
Practice Address - Fax:847-524-4991
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT-36699Medicare UPIN
IL509670Medicare ID - Type Unspecified