1972607323 NPI number — DR. BERT M PETERSON JR. O.D.

Table of content: DR. BERT M PETERSON JR. O.D. (NPI 1972607323)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972607323 NPI number — DR. BERT M PETERSON JR. O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
BERT
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PETERSON
Provider Other First Name:
BERT
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
O.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1972607323
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/18/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 823
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEDFORD
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24523-0823
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-586-0111
Provider Business Mailing Address Fax Number:
540-586-0111

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1126 E. LYNCHBURG-SALEM TPK
Provider Second Line Business Practice Location Address:
WALMART VISION CENTER
Provider Business Practice Location Address City Name:
BEDFORD
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24523-3446
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-586-0111
Provider Business Practice Location Address Fax Number:
540-586-0111
Provider Enumeration Date:
09/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  0618000348 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 92-3065-3 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 222702 . This is a "LUXOTICA MANAGED CARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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