Provider Demographics
NPI:1336173350
Name:PELT EYE CLINIC, P.A.
Entity Type:Organization
Organization Name:PELT EYE CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:PELT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:850-482-2336
Mailing Address - Street 1:PO BOX 6054
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32447-6054
Mailing Address - Country:US
Mailing Address - Phone:850-482-2336
Mailing Address - Fax:850-526-5337
Practice Address - Street 1:4340 LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-2916
Practice Address - Country:US
Practice Address - Phone:850-482-2336
Practice Address - Fax:850-526-5337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620847900Medicaid
FL0577660001Medicare NSC
45816Medicare ID - Type Unspecified