Roger Leslie Petersen, OD
Individual provider Active NPI Optometrist · Higginsville, MO
NPI 1679515787 · NPPES record last updated Oct 29, 2016
Key facts
- NPI
- 1679515787
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Optometrist 152W00000X
- License
- TO2272 (MO)
- Practice address
- 1817 Main St
Higginsville, MO 64037-1524 - Phone
- (660) 584-2956
- Fax
- (660) 584-3956
- NPI assigned
- Jun 12, 2006
- Sex
- Male
- Sole proprietor
- Yes
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MO
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: No · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20120209000418 | MO | Practitioner - Optometry | 5294843181 | Practice locations: Higginsville, MO |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| TO2272 | MO | MD | Optometrist |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Optometrist | 152W00000X | TO2272 | MO | Yes |
Addresses
Primary practice location
1817 Main St
Higginsville, MO 64037-1524
Mailing address
1817 Main St
Higginsville, MO 64037-1524
Phone (660) 584-2956
Other providers in Higginsville, MO
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Oct 29, 2016. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.