Provider Demographics
NPI:1922147339
Name:SHUMWAY, PETER ALLEN (OD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:ALLEN
Last Name:SHUMWAY
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 1:13923 MONO WAY
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370
Mailing Address - Country:US
Mailing Address - Phone:209-533-2550
Mailing Address - Fax:209-533-2951
Practice Address - Street 1:13923 MONO WAY
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370
Practice Address - Country:US
Practice Address - Phone:209-533-2550
Practice Address - Fax:209-533-2951
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7575T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0075750Medicaid
CASD0075750Medicaid
5479470001Medicare ID - Type Unspecified