Provider Demographics
NPI:1992793806
Name:PEDERSEN, ERIC PAUL (OD)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:PAUL
Last Name:PEDERSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:ERIC
Other - Middle Name:PAUL
Other - Last Name:PEDERSEN
Other - Suffix:SR
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:120 MARTIN DR
Mailing Address - Street 2:
Mailing Address - City:FREDONIA
Mailing Address - State:WI
Mailing Address - Zip Code:53021-9455
Mailing Address - Country:US
Mailing Address - Phone:262-692-9000
Mailing Address - Fax:262-692-2797
Practice Address - Street 1:120 MARTIN DR
Practice Address - Street 2:
Practice Address - City:FREDONIA
Practice Address - State:WI
Practice Address - Zip Code:53021-9455
Practice Address - Country:US
Practice Address - Phone:262-692-9000
Practice Address - Fax:262-692-2797
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2013-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2745152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U78038Medicare UPIN