Provider Demographics
NPI:1821173972
Name:PEDERSEN, ROBERT E (OD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:E
Last Name:PEDERSEN
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 1:255 E WEBER AVE
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95202-2706
Mailing Address - Country:US
Mailing Address - Phone:209-466-5566
Mailing Address - Fax:209-466-0535
Practice Address - Street 1:255 E WEBER AVE
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-2706
Practice Address - Country:US
Practice Address - Phone:209-466-5566
Practice Address - Fax:209-466-5566
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT8002TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABU701YMedicare PIN
CASD0080021Medicare PIN
CABU701WMedicare PIN
BU701ZMedicare PIN
CABU701XMedicare PIN
CABU701VMedicare PIN
CAU12255Medicare UPIN
CABU701TMedicare PIN