MEDICARE: SCOTT PETERSON D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	5101019986	MI

General Provider Information

NPI Number	:	1598121808
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SCOTT PETERSON D.O.

Provider Business Mailing Address
First Line	:	3777 COON RAPIDS BLVD NW STE 100
Second Line	:
City	:	COON RAPIDS
State	:	MN
Zip	:	55433-2630
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3777 COON RAPIDS BLVD NW STE 100
Second Line	:
City	:	COON RAPIDS
State	:	MN
Zip	:	55433-2630
Country	:	US
Telephone Number	:	763-421-7420
Fax Number	:	763-421-0730

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/04/2016
Last Update Date	:	03/17/2018

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