Provider Demographics
NPI:1184724692
Name:PETERS, OWEN JOSEPH (OD)
Entity type:Individual
Prefix:
First Name:OWEN
Middle Name:JOSEPH
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 1:801 E 233RD ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10466-3203
Mailing Address - Country:US
Mailing Address - Phone:347-603-7125
Mailing Address - Fax:347-603-7127
Practice Address - Street 1:801 E 233RD ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10466-3203
Practice Address - Country:US
Practice Address - Phone:347-603-7125
Practice Address - Fax:347-603-7127
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV6250152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02078146Medicaid
NYC65981Medicare ID - Type Unspecified
NY02078146Medicaid