Provider Demographics
NPI:1073655437
Name:MOCKLIS, PETER K (OD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:K
Last Name:MOCKLIS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:PANTELIS
Other - Middle Name:K
Other - Last Name:MOUCHLIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
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 1:827 CENTRAL AVE STE 3
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:NH
Practice Address - Zip Code:03820-2577
Practice Address - Country:US
Practice Address - Phone:603-343-1123
Practice Address - Fax:603-343-1405
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3938152W00000X
NH637152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHRE4074Medicare PIN
NHU61080Medicare UPIN