Provider Demographics
NPI:1518982065
Name:KLEM, PETER SHERMAN (OD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:SHERMAN
Last Name:KLEM
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 1:1263 PLEASANT GROVE BLVD
Mailing Address - Street 2:STE. 100
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-5858
Mailing Address - Country:US
Mailing Address - Phone:916-773-1195
Mailing Address - Fax:916-773-1187
Practice Address - Street 1:1263 PLEASANT GROVE BLVD
Practice Address - Street 2:STE. 100
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95747-5858
Practice Address - Country:US
Practice Address - Phone:916-773-1195
Practice Address - Fax:916-773-1187
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6478T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0064782Medicaid
CASD0064782Medicare ID - Type Unspecified
CASD0064782Medicaid