Provider Demographics
NPI:1922078583
Name:IM, PETER O (OD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:O
Last Name:IM
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 1:3475 N SARATOGA ST
Mailing Address - Street 2:
Mailing Address - City:OAK HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98278-4927
Mailing Address - Country:US
Mailing Address - Phone:360-257-9600
Mailing Address - Fax:
Practice Address - Street 1:2080 CHILD ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32214-5005
Practice Address - Country:US
Practice Address - Phone:904-542-7194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3677152W00000X
OR2912AT152W00000X
CA11597T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist