Healthcare Provider Details

I. General information

NPI: 1376536813
Provider Name (Legal Business Name): PHILLIP WARREN PETTERBORG OD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 TUSKEGEE BLVD
DOVER AFB DE
19902-5300
US

IV. Provider business mailing address

906 E PEBWORTH RD
MAGNOLIA DE
19962-1848
US

V. Phone/Fax

Practice location:
  • Phone: 302-677-2574
  • Fax: 302-677-2526
Mailing address:
  • Phone: 302-697-6176
  • Fax: 302-677-2525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODP-730
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: