Provider Demographics
NPI:1457492704
Name:PESTA, RICHARD MATTHEW (OD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:MATTHEW
Last Name:PESTA
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 1:1221B NATIONAL HWY
Mailing Address - Street 2:
Mailing Address - City:LAVALE
Mailing Address - State:MD
Mailing Address - Zip Code:21502-7602
Mailing Address - Country:US
Mailing Address - Phone:301-729-4240
Mailing Address - Fax:301-729-8636
Practice Address - Street 1:1221B NATIONAL HWY
Practice Address - Street 2:
Practice Address - City:LAVALE
Practice Address - State:MD
Practice Address - Zip Code:21502-7602
Practice Address - Country:US
Practice Address - Phone:301-729-4240
Practice Address - Fax:301-729-8636
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA1712152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U79116Medicare UPIN