Provider Demographics
NPI:1245337104
Name:PETERSON, WARREN HOWARD (OD)
Entity type:Individual
Prefix:
First Name:WARREN
Middle Name:HOWARD
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 1:123 W SALEM AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANOLA
Mailing Address - State:IA
Mailing Address - Zip Code:50125-2518
Mailing Address - Country:US
Mailing Address - Phone:515-961-2809
Mailing Address - Fax:515-961-0768
Practice Address - Street 1:123 W SALEM AVE
Practice Address - Street 2:
Practice Address - City:INDIANOLA
Practice Address - State:IA
Practice Address - Zip Code:50125-2518
Practice Address - Country:US
Practice Address - Phone:515-961-2809
Practice Address - Fax:515-961-0768
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01825152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1219980Medicaid
IA22-0315OtherUNITED HEALTH CARE
IA26901OtherBLUE CROSS BLUE SHIELD
IA67284OtherCOVENTRY HEALTH CARE
IA26901Medicare ID - Type Unspecified
IA26901OtherBLUE CROSS BLUE SHIELD