Provider Demographics
NPI:1649216235
Name:PETERSON, GARRICK KEVIN (OD)
Entity Type:Individual
Prefix:DR
First Name:GARRICK
Middle Name:KEVIN
Last Name:PETERSON
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 928
Mailing Address - Street 2:
Mailing Address - City:LINDSAY
Mailing Address - State:CA
Mailing Address - Zip Code:93247-0928
Mailing Address - Country:US
Mailing Address - Phone:559-562-4963
Mailing Address - Fax:559-562-1333
Practice Address - Street 1:141 S MIRAGE AVE
Practice Address - Street 2:
Practice Address - City:LINDSAY
Practice Address - State:CA
Practice Address - Zip Code:93247-2541
Practice Address - Country:US
Practice Address - Phone:559-562-4963
Practice Address - Fax:559-562-1333
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-21
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9157T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADS0091570Medicaid
CADS0091570Medicaid
CASD0091570Medicare PIN