Provider Demographics
NPI:1942273545
Name:PETERS, JOSEPH R (OD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:R
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 1:164 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:DELTA
Mailing Address - State:CO
Mailing Address - Zip Code:81416-1842
Mailing Address - Country:US
Mailing Address - Phone:970-874-8110
Mailing Address - Fax:970-874-5348
Practice Address - Street 1:164 W 3RD ST
Practice Address - Street 2:
Practice Address - City:DELTA
Practice Address - State:CO
Practice Address - Zip Code:81416-1842
Practice Address - Country:US
Practice Address - Phone:970-874-8110
Practice Address - Fax:970-874-5348
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1267152W00000X
MT820152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ72347Medicare PIN
AZZ84074Medicare PIN
AZU52936Medicare UPIN
MTM011000472Medicare PIN