Provider Demographics
NPI:1356482798
Name:RICHARD J PEACH OD INC
Entity Type:Organization
Organization Name:RICHARD J PEACH OD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:PEACH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:219-836-5326
Mailing Address - Street 1:800 MACARTHUR BLVD
Mailing Address - Street 2:SUITE 10
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-2917
Mailing Address - Country:US
Mailing Address - Phone:219-836-5326
Mailing Address - Fax:219-836-5326
Practice Address - Street 1:800 MACARTHUR BLVD
Practice Address - Street 2:SUITE 10
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2917
Practice Address - Country:US
Practice Address - Phone:219-836-5326
Practice Address - Fax:219-836-5326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001668A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0509220001OtherDMERC
IN627720Medicare ID - Type Unspecified
IN0509220001OtherDMERC
IN0509220001Medicare NSC