Provider Demographics
NPI:1629561428
Name:OPTOMETRIC SPECIALTY GROUP OF WETHERSFIELD, PLLC
Entity Type:Organization
Organization Name:OPTOMETRIC SPECIALTY GROUP OF WETHERSFIELD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:PEGOLO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:860-236-1218
Mailing Address - Street 1:612 QUAKER LN S STE B
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06110-1027
Mailing Address - Country:US
Mailing Address - Phone:860-236-1218
Mailing Address - Fax:860-231-9298
Practice Address - Street 1:185 SILAS DEANE HWY
Practice Address - Street 2:
Practice Address - City:WETHERSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06109-1219
Practice Address - Country:US
Practice Address - Phone:860-296-1700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-07
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty