Healthcare Provider Details

I. General information

NPI: 1285314237
Provider Name (Legal Business Name): MARIE PETERSON OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARIE MULLALLY

II. Dates (important events)

Enumeration Date: 07/24/2023
Last Update Date: 07/24/2023
Certification Date: 07/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4281 24TH AVE
FORT GRATIOT MI
48059-3997
US

IV. Provider business mailing address

6401 BURTCH RD
JEDDO MI
48032-2720
US

V. Phone/Fax

Practice location:
  • Phone: 810-385-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901005688
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: