MEDICARE: DR. JESSE N PETERMAN O.D.

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	152W00000X	Optometrist	046009781	IL

General Provider Information

NPI Number	:	1851482194
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JESSE N PETERMAN O.D.

Provider Business Mailing Address
First Line	:	2 W TALCOTT RD
Second Line	:	LOSSMAN EYE CARE ASSOCIATES
City	:	PARK RIDGE
State	:	IL
Zip	:	60068-5556
Country	:	US
Telephone Number	:	630-674-7991
Fax Number	:

Provider Business Practice Location Address
First Line	:	1114 W DEVON AVE
Second Line	:
City	:	ELK GROVE VILLAGE
State	:	IL
Zip	:	60007-3214
Country	:	US
Telephone Number	:	847-895-7222
Fax Number	:	847-895-0861

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

Provider Enumeration Date	:	09/28/2006
Last Update Date	:	11/03/2023

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