Provider Demographics
NPI:1386803534
Name:WARREN H. PETERSON, O.D.
Entity type:Organization
Organization Name:WARREN H. PETERSON, O.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WARREN
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:515-961-2809
Mailing Address - Street 1:123 W SALEM AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANOLA
Mailing Address - State:IA
Mailing Address - Zip Code:50125-2518
Mailing Address - Country:US
Mailing Address - Phone:515-961-2809
Mailing Address - Fax:515-961-0768
Practice Address - Street 1:123 W SALEM AVE
Practice Address - Street 2:
Practice Address - City:INDIANOLA
Practice Address - State:IA
Practice Address - Zip Code:50125-2518
Practice Address - Country:US
Practice Address - Phone:515-961-2809
Practice Address - Fax:515-961-0768
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAIA1825332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0822510001Medicare NSC