Provider Demographics
NPI:1316937840
Name:PETERSEN, CHRISTOPHER GLEN (OD)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:GLEN
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:PO BOX 488
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:WA
Mailing Address - Zip Code:98848-0488
Mailing Address - Country:US
Mailing Address - Phone:509-787-1581
Mailing Address - Fax:509-787-9176
Practice Address - Street 1:701 2ND AVE SE
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:WA
Practice Address - Zip Code:98848-1531
Practice Address - Country:US
Practice Address - Phone:509-787-1581
Practice Address - Fax:509-787-9176
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-26
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD1175TX152W00000X
ID0573152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2021194Medicaid
WA2021194Medicaid
WA0207880001Medicare NSC
T02376Medicare UPIN