Provider Demographics
NPI:1477987741
Name:PETERSON, BRIAN MICHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:MICHAEL
Last Name:PETERSON
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 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:15 CYPRESS BRANCH WAY STE 205
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-8414
Practice Address - Country:US
Practice Address - Phone:386-445-1880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-22
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 4830152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOPC 4830OtherFLORIDA LICENSE NUMBER