Provider Demographics
NPI:1699780262
Name:PETERSOHN, MELISSA (OD)
Entity type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:
Last Name:PETERSOHN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:BAYARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:2130 BALDWIN CT
Mailing Address - Street 2:
Mailing Address - City:HANOVER PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60133-2966
Mailing Address - Country:US
Mailing Address - Phone:312-636-1504
Mailing Address - Fax:
Practice Address - Street 1:700 E HIGGINS RD
Practice Address - Street 2:
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60173-4701
Practice Address - Country:US
Practice Address - Phone:847-884-8799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-30
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-009778152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist