Provider Demographics
NPI:1912335746
Name:OPTUM
Entity Type:Organization
Organization Name:OPTUM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MR
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:L
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP-BC
Authorized Official - Phone:813-293-4609
Mailing Address - Street 1:701 N WILDER RD
Mailing Address - Street 2:
Mailing Address - City:PLANT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33566-7547
Mailing Address - Country:US
Mailing Address - Phone:813-293-4609
Mailing Address - Fax:
Practice Address - Street 1:701 N WILDER RD
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33566-7547
Practice Address - Country:US
Practice Address - Phone:813-293-4609
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-14
Last Update Date:2013-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9285722305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service