Provider Demographics
NPI:1801999388
Name:PETERSEN, JAY (OD)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:
Last Name:PETERSEN
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 1:3333 HAZELTON RD
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-4204
Mailing Address - Country:US
Mailing Address - Phone:952-926-5300
Mailing Address - Fax:952-915-9212
Practice Address - Street 1:N-236 NORTH GARDEN
Practice Address - Street 2:MALL OF AMERICA
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55425
Practice Address - Country:US
Practice Address - Phone:952-854-4500
Practice Address - Fax:952-858-8525
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN1697152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2203100OtherMEDICA/UNITED HEALTH CARE
MN23713OtherAMERICA'S PPO
MNMN1697OtherEYEMED
MN190P9PEOtherBCBS/MN
MN23713OtherAMERICA'S PPO