Provider Demographics
NPI:1922577469
Name:PETERSON, KRISTEN KATHLEEN (OD)
Entity type:Individual
Prefix:DR
First Name:KRISTEN
Middle Name:KATHLEEN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8614 WESTWOOD CENTER DR FL 9
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-2442
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:
Practice Address - Street 1:135 MAIN ST STE 5
Practice Address - Street 2:
Practice Address - City:STURBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01566-1569
Practice Address - Country:US
Practice Address - Phone:508-347-7309
Practice Address - Fax:508-347-7451
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-14
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5323152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty