Provider Demographics
NPI:1568449353
Name:PETERS, TRACI MAXWELL (OD)
Entity Type:Individual
Prefix:DR
First Name:TRACI
Middle Name:MAXWELL
Last Name:PETERS
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 1:707 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80905-1811
Mailing Address - Country:US
Mailing Address - Phone:719-477-0274
Mailing Address - Fax:719-633-1109
Practice Address - Street 1:707 S 8TH ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80905-1811
Practice Address - Country:US
Practice Address - Phone:719-477-0274
Practice Address - Fax:719-633-1109
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-22
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6449TG152W00000X
CO2638152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO21436541Medicaid
COCO305455Medicare PIN