Provider Demographics
NPI:1689751885
Name:PETERSON, STEVEN JOSEPH (OD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:JOSEPH
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 1:505 STATE STREET
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:MN
Mailing Address - Zip Code:56175-1539
Mailing Address - Country:US
Mailing Address - Phone:507-629-3230
Mailing Address - Fax:507-629-3230
Practice Address - Street 1:505 STATE STREET
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:MN
Practice Address - Zip Code:56175-1539
Practice Address - Country:US
Practice Address - Phone:507-629-3230
Practice Address - Fax:507-629-3230
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2056152W00000X
WI2101152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN3C276PBOtherBLUE PLUS
MN410011573OtherMEDICARE RAILROAD
MN697823100Medicaid
MN898861020124OtherPREFERRED CHOICES
MN112984OtherUCARE
MN43233PBOtherBCBS
MN898861020124OtherPREFERRED CHOICES
MN697823100Medicaid