Provider Demographics
NPI:1710569819
Name:STAN, PETER JOHN (OD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:JOHN
Last Name:STAN
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 1:4920 LYNN PL NW
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44483-1444
Mailing Address - Country:US
Mailing Address - Phone:330-272-3998
Mailing Address - Fax:
Practice Address - Street 1:163 VETERANS DRIVE
Practice Address - Street 2:
Practice Address - City:WHITE RIVER JUNCTION
Practice Address - State:VT
Practice Address - Zip Code:05009-0001
Practice Address - Country:US
Practice Address - Phone:802-295-9363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-27
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOPT.006933152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist