Provider Demographics
NPI:1477853364
Name:C S PETERS OD, PA
Entity type:Organization
Organization Name:C S PETERS OD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:C
Authorized Official - Middle Name:S
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-678-1722
Mailing Address - Street 1:111 N JOHN SIMS PKWY
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:FL
Mailing Address - Zip Code:32580-1005
Mailing Address - Country:US
Mailing Address - Phone:850-678-1722
Mailing Address - Fax:
Practice Address - Street 1:111 N JOHN SIMS PKWY
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:FL
Practice Address - Zip Code:32580-1005
Practice Address - Country:US
Practice Address - Phone:850-678-1722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-26
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOP0001109152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL084488800Medicaid
FL0608190001Medicare NSC
FL084488800Medicaid
FLT84068Medicare UPIN