Provider Demographics
NPI:1386025864
Name:LEPINSKI-PETERSON, MIRANDA (OD)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:LEPINSKI-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 1:560 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MN
Mailing Address - Zip Code:55362-8403
Mailing Address - Country:US
Mailing Address - Phone:763-270-2020
Mailing Address - Fax:
Practice Address - Street 1:560 CEDAR ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362-8403
Practice Address - Country:US
Practice Address - Phone:763-270-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-10
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3436152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1386025864Medicaid