Healthcare Provider Details

I. General information

NPI: 1992829006
Provider Name (Legal Business Name): ROGER L PETERSEN OD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1817 N MAIN ST
HIGGINSVILLE MO
64037-1524
US

IV. Provider business mailing address

1817 N MAIN ST
HIGGINSVILLE MO
64037-1524
US

V. Phone/Fax

Practice location:
  • Phone: 660-584-2956
  • Fax: 660-584-3956
Mailing address:
  • Phone: 660-584-2956
  • Fax: 660-584-3956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTO2272
License Number StateMO

VIII. Authorized Official

Name: DR. ROGER LESLIE PETERSEN
Title or Position: OWNER
Credential: OD
Phone: 660-584-2956