Provider Demographics
NPI:1407867161
Name:PETERSEN, RICHARD NELS (OD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:NELS
Last Name:PETERSEN
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 1:1745 W AVENUE K
Mailing Address - Street 2:SUITE A
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-6502
Mailing Address - Country:US
Mailing Address - Phone:661-942-8437
Mailing Address - Fax:661-940-1959
Practice Address - Street 1:1745 W AVENUE K
Practice Address - Street 2:SUITE A
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-6502
Practice Address - Country:US
Practice Address - Phone:661-942-8437
Practice Address - Fax:661-940-1959
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2008-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13129152W00000X
CA0PT13129T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD13129T0OtherBLUECROSS/BLUE SHIELD
CA14156OtherMESC
CA14156OtherMESC
CAV10864Medicare UPIN
CAWOP13129AMedicare PIN