Provider Demographics
NPI:1972553899
Name:PETERS, ROBERT J (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:J
Last Name:PETERS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:5050 CASCADE RD SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3725
Mailing Address - Country:US
Mailing Address - Phone:616-957-0866
Mailing Address - Fax:616-957-4102
Practice Address - Street 1:5050 CASCADE RD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3725
Practice Address - Country:US
Practice Address - Phone:616-957-0866
Practice Address - Fax:616-957-4102
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI003979152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4362760Medicaid
MI13857OtherPRIORITY HEALTH HMO
MI900D166360OtherBLUE CROSS BLUE SHIELD
MI4362760OtherCHILDREN SPECIAL HEALTH
MI13857OtherPRIORITY HEALTH MEDICAID
MI900D166360OtherFEP BLUE CROSS
MI900D166360OtherFEP BLUE CROSS