Provider Demographics
NPI:1134180649
Name:TIBBETTS, PETER E (OD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:E
Last Name:TIBBETTS
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 1:2921 ERIE BLVD E
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13224
Mailing Address - Country:US
Mailing Address - Phone:315-445-7465
Mailing Address - Fax:315-445-7675
Practice Address - Street 1:125 LAWRENCE RD E
Practice Address - Street 2:EMPIRE VISION CENTERS
Practice Address - City:NORTH SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13212
Practice Address - Country:US
Practice Address - Phone:315-455-5500
Practice Address - Fax:315-455-8619
Is Sole Proprietor?:No
Enumeration Date:2006-04-01
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT0054891152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCC8167Medicare ID - Type Unspecified
U48654Medicare UPIN
NYRB0369Medicare PIN
NYRB0368Medicare PIN
NYRB0367Medicare PIN