Provider Demographics
NPI:1902973415
Name:PETERSON, CHARLES WALTER (OD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:WALTER
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 1:904 ELLIOTT AVE N
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-1666
Mailing Address - Country:US
Mailing Address - Phone:509-860-2453
Mailing Address - Fax:
Practice Address - Street 1:904 ELLIOTT AVE N
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-1666
Practice Address - Country:US
Practice Address - Phone:509-860-2453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00003914152W00000X
MT697152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2030641Medicaid
WA5348840001Medicare NSC
WAG8854291Medicare PIN
WA2030641Medicaid