Provider Demographics
NPI:1174509996
Name:PETERS, CAROL L (OD)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:L
Last Name:PETERS
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 1:102 EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:MILLIKEN
Mailing Address - State:CO
Mailing Address - Zip Code:80543-9623
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2867 35TH AVE
Practice Address - Street 2:SUITE A
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-9407
Practice Address - Country:US
Practice Address - Phone:970-346-1411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOPT-1223152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COT60851Medicare UPIN
COC468458Medicare PIN