Provider Demographics
NPI:1063462174
Name:REMILLARD, PETER A (OD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:A
Last Name:REMILLARD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:865 LAFAYETTE RD
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:NH
Practice Address - Zip Code:03842-1257
Practice Address - Country:US
Practice Address - Phone:603-926-2722
Practice Address - Fax:603-926-2898
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3452152W00000X
NH1034152W00000X
CT002193152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004161056Medicaid