Provider Demographics
NPI:1275582553
Name:DODGE, PETER E (OD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:E
Last Name:DODGE
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 1:4371 UNION DEPOSIT RD
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17111-2905
Mailing Address - Country:US
Mailing Address - Phone:717-561-1660
Mailing Address - Fax:717-561-8314
Practice Address - Street 1:4371 UNION DEPOSIT RD
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17111-2905
Practice Address - Country:US
Practice Address - Phone:717-561-1660
Practice Address - Fax:717-561-8314
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-06
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000403152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA50003812OtherCAPITAL BLUE CROSS
PA096486OtherHIGHMARK BLUE SHIELD
PA50003812OtherCAPITAL BLUE CROSS
PA096486OtherHIGHMARK BLUE SHIELD
PAT28516Medicare UPIN