Provider Demographics
NPI:1972607323
Name:PETERSON, BERT M JR (OD)
Entity Type:Individual
Prefix:DR
First Name:BERT
Middle Name:M
Last Name:PETERSON
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:BERT
Other - Middle Name:
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 823
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:VA
Mailing Address - Zip Code:24523-0823
Mailing Address - Country:US
Mailing Address - Phone:540-586-0111
Mailing Address - Fax:540-586-0111
Practice Address - Street 1:1126 E. LYNCHBURG-SALEM TPK
Practice Address - Street 2:WALMART VISION CENTER
Practice Address - City:BEDFORD
Practice Address - State:VA
Practice Address - Zip Code:24523-3446
Practice Address - Country:US
Practice Address - Phone:540-586-0111
Practice Address - Fax:540-586-0111
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000348152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA92-3065-3Medicaid
VA222702OtherLUXOTICA MANAGED CARE
VA92-3065-3Medicaid