Provider Demographics
NPI:1407843535
Name:THEODOROUS, PETER G (OD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:G
Last Name:THEODOROUS
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 1:428 WINDMERE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16801-7668
Mailing Address - Country:US
Mailing Address - Phone:814-234-2015
Mailing Address - Fax:814-238-5300
Practice Address - Street 1:4570 PENNS VALLEY RD
Practice Address - Street 2:SUITE 3
Practice Address - City:SPRING MILLS
Practice Address - State:PA
Practice Address - Zip Code:16875-8500
Practice Address - Country:US
Practice Address - Phone:814-422-8006
Practice Address - Fax:814-422-8561
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000709152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
621315Medicare ID - Type Unspecified
T98343Medicare UPIN