Provider Demographics
NPI:1922349836
Name:KOERNER, PETER JOHN (OD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:JOHN
Last Name:KOERNER
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 1:10110 TWO NOTCH RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-4383
Mailing Address - Country:US
Mailing Address - Phone:803-365-9024
Mailing Address - Fax:803-788-4899
Practice Address - Street 1:9741 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46229-3035
Practice Address - Country:US
Practice Address - Phone:317-869-0975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-04
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003767A152W00000X
SC1806152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist