Provider Demographics
NPI:1457085722
Name:OPTOMETRIC SPECIALTY GROUP OF SIMSBURY PLLC
Entity Type:Organization
Organization Name:OPTOMETRIC SPECIALTY GROUP OF SIMSBURY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OD/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:PEGOLO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:860-658-1620
Mailing Address - Street 1:883 HOPMEADOW ST
Mailing Address - Street 2:
Mailing Address - City:SIMSBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06070-1884
Mailing Address - Country:US
Mailing Address - Phone:860-658-1620
Mailing Address - Fax:860-658-7923
Practice Address - Street 1:883 HOPMEADOW ST
Practice Address - Street 2:
Practice Address - City:SIMSBURY
Practice Address - State:CT
Practice Address - Zip Code:06070-1884
Practice Address - Country:US
Practice Address - Phone:860-658-1620
Practice Address - Fax:860-658-7923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-13
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty