Provider Demographics
NPI:1639369127
Name:PETERSON, ELIZABETH MARIE (OD)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:MARIE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:MARIE
Other - Last Name:WERNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:103 W SAINT CLAIR ST RM 1A
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:PA
Mailing Address - Zip Code:16365-2187
Mailing Address - Country:US
Mailing Address - Phone:814-726-2020
Mailing Address - Fax:814-726-1215
Practice Address - Street 1:103 W SAINT CLAIR ST RM 1A
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:PA
Practice Address - Zip Code:16365-2187
Practice Address - Country:US
Practice Address - Phone:814-726-2020
Practice Address - Fax:814-726-1215
Is Sole Proprietor?:No
Enumeration Date:2007-07-31
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1688152W00000X
MA4667152W00000X
CT002720152W00000X
PAOEG003245152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0718441Medicaid
MA137525OtherFALLON
MA9845135OtherAETNA
MAMA4667OtherEYEMED
MA04-2945394OtherUNITED HEALTHCARE
MAAA111986OtherHARVARD PILGRIM
MA214521-7908OtherCONNECTICARE
MA43787OtherHEALTH NEW ENGLAND
MA000642201Medicare PIN
MA9845135OtherAETNA