Provider Demographics
NPI:1841381340
Name:PETERSON, RICK E (OD)
Entity Type:Individual
Prefix:DR
First Name:RICK
Middle Name:E
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 1:5553 127TH ST
Mailing Address - Street 2:
Mailing Address - City:CRESTWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60418-1123
Mailing Address - Country:US
Mailing Address - Phone:708-371-5160
Mailing Address - Fax:
Practice Address - Street 1:5553 127TH ST
Practice Address - Street 2:
Practice Address - City:CRESTWOOD
Practice Address - State:IL
Practice Address - Zip Code:60445-1123
Practice Address - Country:US
Practice Address - Phone:708-371-5160
Practice Address - Fax:708-930-1844
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008476152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILDA0516OtherMEDICARE RR GROUP
ILP00005574OtherMEDICARE RR
ILL95317OtherMEDICARE INDIVIDUAL
IL0514170001OtherMEDICARE DME GROUP
IL0514170002OtherMEDICARE DME GROUP
ILDA0515OtherMEDICARE RR GROUP
IL203865OtherMEDICARE GROUP
ILP00005582OtherMEDICARE RR
ILL95316OtherMEDICARE INDIVIDUAL
IL203866OtherMEDICARE GROUP
IL203865OtherMEDICARE GROUP
IL203866OtherMEDICARE GROUP
IL363860173OtherTAX ID NUMBER