Provider Demographics
NPI:1760741573
Name:STEVEN G. PETERSON, O.D., INC.
Entity Type:Organization
Organization Name:STEVEN G. PETERSON, O.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:GENE
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:619-286-2819
Mailing Address - Street 1:7090 PARKWAY DR
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-1596
Mailing Address - Country:US
Mailing Address - Phone:619-286-2810
Mailing Address - Fax:619-286-0597
Practice Address - Street 1:7090 PARKWAY DR
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-1596
Practice Address - Country:US
Practice Address - Phone:619-286-2810
Practice Address - Fax:619-286-0597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-14
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT7554152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT70207Medicare UPIN
CAGF300AMedicare PIN