Provider Demographics
NPI:1720490980
Name:EUDENBACH, PETER T (OD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:T
Last Name:EUDENBACH
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 1:416 GIBBS AVE
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:RI
Mailing Address - Zip Code:02840-3327
Mailing Address - Country:US
Mailing Address - Phone:401-847-0961
Mailing Address - Fax:401-847-6301
Practice Address - Street 1:58 E MAIN RD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:RI
Practice Address - Zip Code:02842-4912
Practice Address - Country:US
Practice Address - Phone:401-846-1620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-22
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIODTA00287152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist