Provider Demographics
NPI:1114043387
Name:PETERSON, THOMAS G (OD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:G
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 1:150A COUNTY ROAD B
Mailing Address - Street 2:
Mailing Address - City:SHAWANO
Mailing Address - State:WI
Mailing Address - Zip Code:54166-7072
Mailing Address - Country:US
Mailing Address - Phone:715-526-3163
Mailing Address - Fax:715-526-4019
Practice Address - Street 1:150A COUNTY ROAD B
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166
Practice Address - Country:US
Practice Address - Phone:715-526-3163
Practice Address - Fax:715-526-4019
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2018-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2324152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI410033786OtherRAILROAD MEDICARE
WI38578000Medicaid
WI0469110001Medicare NSC
WI410033786OtherRAILROAD MEDICARE
WIT83426Medicare UPIN