Provider Demographics
NPI:1902866130
Name:PETERS, RANDY L (OD)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:L
Last Name:PETERS
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 1:219 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:OH
Mailing Address - Zip Code:43506-1759
Mailing Address - Country:US
Mailing Address - Phone:419-636-3937
Mailing Address - Fax:
Practice Address - Street 1:219 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:OH
Practice Address - Zip Code:43506-1759
Practice Address - Country:US
Practice Address - Phone:419-636-3937
Practice Address - Fax:419-636-2302
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4624 T1371152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9354861Medicare ID - Type Unspecified
OH1116050004Medicare NSC
OHU59869Medicare UPIN