Provider Demographics
NPI:1205801032
Name:PELOWSKI, DAVID B (OD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:B
Last Name:PELOWSKI
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 1:424 BARCLAY AVE.
Mailing Address - Street 2:P O BOX 457
Mailing Address - City:PINE RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:56474-0457
Mailing Address - Country:US
Mailing Address - Phone:218-587-2020
Mailing Address - Fax:218-587-3229
Practice Address - Street 1:14453 EDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425-8459
Practice Address - Country:US
Practice Address - Phone:218-829-1789
Practice Address - Fax:218-829-1780
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2699152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN197023200Medicaid
MN410002147Medicare ID - Type Unspecified
MNU74864Medicare UPIN