Provider Demographics
NPI:1609846625
Name:ACHENBACH, PEGGY (OD)
Entity Type:Individual
Prefix:DR
First Name:PEGGY
Middle Name:
Last Name:ACHENBACH
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 1:55 SPARTA AVE
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:NJ
Mailing Address - Zip Code:07871-1815
Mailing Address - Country:US
Mailing Address - Phone:973-729-3839
Mailing Address - Fax:973-726-0651
Practice Address - Street 1:2215 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501
Practice Address - Country:US
Practice Address - Phone:912-285-2021
Practice Address - Fax:912-285-2558
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJOA00005411152W00000X, 152WC0802X, 152WP0200X
GAOPT003079152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AC478696Medicare ID - Type Unspecified