Provider Demographics
NPI:1528192465
Name:KAREN PESCHKE, O.D., A PROFESSIONAL CORPORATION OF OPTOMETRY
Entity Type:Organization
Organization Name:KAREN PESCHKE, O.D., A PROFESSIONAL CORPORATION OF OPTOMETRY
Other - Org Name:CHINN & PESCHKE, APC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:LILYAN
Authorized Official - Last Name:PESCHKE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:760-744-3002
Mailing Address - Street 1:181 S RANCHO SANTA FE RD
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-2501
Mailing Address - Country:US
Mailing Address - Phone:760-744-3002
Mailing Address - Fax:760-744-3050
Practice Address - Street 1:181 S RANCHO SANTA FE RD
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92078-2501
Practice Address - Country:US
Practice Address - Phone:760-744-3002
Practice Address - Fax:760-744-3050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACOR 1204152W00000X
CA12260152W00000X
CAOPT 12260152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABY722AMedicare PIN