Provider Demographics
NPI:1477533909
Name:WEBER, PETER G (OD)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:G
Last Name:WEBER
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:PO BOX 6550
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46904-6550
Mailing Address - Country:US
Mailing Address - Phone:765-453-5696
Mailing Address - Fax:765-455-4323
Practice Address - Street 1:1601 W LINCOLN RD
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902
Practice Address - Country:US
Practice Address - Phone:765-453-5696
Practice Address - Fax:765-455-4323
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003483A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200912700Medicaid
INM400024478Medicare PIN
INP00640356Medicare PIN
SD41843Medicare ID - Type Unspecified
INM400037167Medicare PIN
IN200912700Medicaid
IN252690FMedicare PIN
IN160450012Medicare PIN
IN452570021Medicare PIN