Active NPI
Phillip Warren Petterborg, OD
- Optometrist
- Dover Afb, DE
National Provider Identifier
1376536813
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Optometrist
- License
- ODP-730
- Practice address
- 300 Tuskegee Blvd
Dover Afb, DE 19902-5300 - Phone
- (302) 677-2574
- Fax
- (302) 677-2526
- NPI assigned
- Aug 30, 2005
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Optometrist | 152W00000X | ODP-730 | ID | Primary |
Addresses
Primary practice location
300 Tuskegee Blvd
Dover Afb, DE 19902-5300
Mailing address
906 E Pebworth Rd
Magnolia, DE 19962-1848
Phone (302) 697-6176
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| ODP-730 | ID | MD | Optometrist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1125360000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1783900800000",
"number": "1376536813",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "906 E PEBWORTH RD",
"city": "MAGNOLIA",
"state": "DE",
"postal_code": "199621848",
"telephone_number": "302-697-6176",
"fax_number": "302-677-2525"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "300 TUSKEGEE BLVD",
"city": "DOVER AFB",
"state": "DE",
"postal_code": "199025300",
"telephone_number": "302-677-2574",
"fax_number": "302-677-2526"
}
],
"practiceLocations": [],
"basic": {
"last_name": "PETTERBORG",
"first_name": "PHILLIP",
"middle_name": "WARREN",
"name_prefix": "Dr.",
"credential": "OD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2005-08-30",
"last_updated": "2026-07-13",
"status": "A"
},
"taxonomies": [
{
"code": "152W00000X",
"taxonomy_group": "",
"desc": "Optometrist",
"state": "ID",
"license": "ODP-730",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Dover Afb, DE
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 13, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.