Healthcare Provider Details

I. General information

NPI: 1376514372
Provider Name (Legal Business Name): DAVID L. PETERS O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2006
Last Update Date: 04/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 W STATE ST
SAINT JOHNS MI
48879-1451
US

IV. Provider business mailing address

611 W STATE ST P.O.BOX 204
SAINT JOHNS MI
48879-1451
US

V. Phone/Fax

Practice location:
  • Phone: 989-224-6651
  • Fax: 989-224-7024
Mailing address:
  • Phone: 989-224-6651
  • Fax: 989-224-7024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number002404
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: