Provider Demographics
NPI:1720297740
Name:PETERSON, RIC DONALD (OD)
Entity Type:Individual
Prefix:DR
First Name:RIC
Middle Name:DONALD
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 1:3900 W WHEATLAND RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75237-3468
Mailing Address - Country:US
Mailing Address - Phone:972-780-7199
Mailing Address - Fax:
Practice Address - Street 1:3900 W WHEATLAND RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75237-3468
Practice Address - Country:US
Practice Address - Phone:972-780-7199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4304152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX197166501OtherMEDICAID - GROUP TPI#
TX005FBOtherBCBSTX - GROUP#
TX329106401Medicaid
TX00Y945OtherNSC -MEDICARE GROUP PTAN#
TX8DW848OtherBLUE CROSS BLUE SHIELD
TX8DW848OtherBLUE CROSS BLUE SHIELD