Provider Demographics
NPI:1720071798
Name:BURGESS-PETERSON, HEATHER MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:MARIE
Last Name:BURGESS-PETERSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15780 RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-1557
Mailing Address - Country:US
Mailing Address - Phone:231-719-9200
Mailing Address - Fax:231-744-6782
Practice Address - Street 1:1871 HOLTON RD
Practice Address - Street 2:SUITE A
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49445-1594
Practice Address - Country:US
Practice Address - Phone:231-719-9200
Practice Address - Fax:231-744-6782
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003806152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU68516Medicare UPIN