Provider Demographics
NPI:1912945726
Name:ROTHERMEL, PETER J (OD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:J
Last Name:ROTHERMEL
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 1:205 B WEST WATER
Mailing Address - Street 2:
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028-2737
Mailing Address - Country:US
Mailing Address - Phone:830-792-5880
Mailing Address - Fax:
Practice Address - Street 1:205 B WEST WATER
Practice Address - Street 2:
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-2737
Practice Address - Country:US
Practice Address - Phone:830-792-5880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX04937T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX80933QOtherBCBS
TX093056201Medicaid
TX80933QOtherBCBS
TXU50216Medicare UPIN
TX00678YMedicare PIN