Provider Demographics
NPI:1598790891
Name:PELT, DAVID G (OD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:G
Last Name:PELT
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:PO BOX 6054
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32447
Mailing Address - Country:US
Mailing Address - Phone:850-482-2336
Mailing Address - Fax:850-526-5337
Practice Address - Street 1:4340 LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446
Practice Address - Country:US
Practice Address - Phone:850-482-2336
Practice Address - Fax:850-526-5337
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1859152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078403600Medicaid
FL19188Medicare ID - Type Unspecified
FL078403600Medicaid