Provider Demographics
NPI:1285314237
Name:PETERSON, MARIE (OD)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:
Other - Last Name:MULLALLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6401 BURTCH RD
Mailing Address - Street 2:
Mailing Address - City:JEDDO
Mailing Address - State:MI
Mailing Address - Zip Code:48032-2720
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4281 24TH AVE
Practice Address - Street 2:
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-3997
Practice Address - Country:US
Practice Address - Phone:810-385-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901005688152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist