Provider Demographics
NPI:1255474219
Name:PETERSON, ANTHONY (OD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:
Last Name:PETERSON
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 1:150 E HIGHWAY 67
Mailing Address - Street 2:SUITE 120
Mailing Address - City:DUNCANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75137-4476
Mailing Address - Country:US
Mailing Address - Phone:972-298-3937
Mailing Address - Fax:972-298-2170
Practice Address - Street 1:150 E HIGHWAY 67
Practice Address - Street 2:SUITE 120
Practice Address - City:DUNCANVILLE
Practice Address - State:TX
Practice Address - Zip Code:75137-4476
Practice Address - Country:US
Practice Address - Phone:972-298-3937
Practice Address - Fax:972-298-2170
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7032TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX196604604OtherMEDICAID PROVIDER TPI#
TX269216OtherMEDICARE PTAN
TXT15301Medicare UPIN
TX269216Medicare PIN