Provider Demographics
NPI:1477747988
Name:PETERSON, INGRID (OD)
Entity Type:Individual
Prefix:DR
First Name:INGRID
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 W LAKE MARY BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32773-5946
Mailing Address - Country:US
Mailing Address - Phone:407-322-2230
Mailing Address - Fax:407-330-6287
Practice Address - Street 1:820 W LAKE MARY BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32773-5946
Practice Address - Country:US
Practice Address - Phone:407-322-2230
Practice Address - Fax:407-330-6287
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-29
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1438152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078034100Medicaid
FLU25967Medicare UPIN
FL078034100Medicaid