Provider Demographics
NPI:1013089283
Name:PETERSON, KEVIN C (OD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:C
Last Name:PETERSON
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 1:1845 LOCKEWAY DR
Mailing Address - Street 2:SUITE 401
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30004-5936
Mailing Address - Country:US
Mailing Address - Phone:770-664-5580
Mailing Address - Fax:
Practice Address - Street 1:1845 LOCKEWAY DR
Practice Address - Street 2:SUITE 401
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30004-5936
Practice Address - Country:US
Practice Address - Phone:770-664-5580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1697152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU72501Medicare UPIN
GA41ZCDKSMedicare ID - Type Unspecified