Provider Demographics
NPI:1760454946
Name:PETERSON, JEFFREY M (OD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:M
Last Name:PETERSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2019 JEFFERSON RD
Mailing Address - Street 2:STE A
Mailing Address - City:NORTHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55057-3258
Mailing Address - Country:US
Mailing Address - Phone:507-645-9202
Mailing Address - Fax:507-645-9203
Practice Address - Street 1:8600 NICOLLET AVE S
Practice Address - Street 2:MAIL STOP 31500A
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55420-2824
Practice Address - Country:US
Practice Address - Phone:952-887-6600
Practice Address - Fax:952-886-7015
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-02
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN2567152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN989014900Medicaid