Provider Demographics
NPI:1518924174
Name:PETERS, RICHARD M (OD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:M
Last Name:PETERS
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 1:810 N AVALON BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:90744-4502
Mailing Address - Country:US
Mailing Address - Phone:310-834-5464
Mailing Address - Fax:310-835-6665
Practice Address - Street 1:810 N AVALON BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:CA
Practice Address - Zip Code:90744-4502
Practice Address - Country:US
Practice Address - Phone:310-834-5464
Practice Address - Fax:310-835-6665
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4741T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0047410Medicaid
CABA265ZMedicare PIN
CAT69943Medicare UPIN
CASD0047410Medicaid