Provider Demographics
NPI:1679515787
Name:PETERSEN, ROGER LESLIE (OD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:LESLIE
Last Name:PETERSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1817 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HIGGINSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64037-1524
Mailing Address - Country:US
Mailing Address - Phone:660-584-2956
Mailing Address - Fax:660-584-3956
Practice Address - Street 1:1817 MAIN ST
Practice Address - Street 2:
Practice Address - City:HIGGINSVILLE
Practice Address - State:MO
Practice Address - Zip Code:64037-1524
Practice Address - Country:US
Practice Address - Phone:660-584-2956
Practice Address - Fax:660-584-3956
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2016-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOTO2272152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0001966Medicare ID - Type Unspecified
T42497Medicare UPIN