Provider Demographics
NPI:1902990161
Name:PETERS, C S (OD PA)
Entity Type:Individual
Prefix:
First Name:C S
Middle Name:
Last Name:PETERS
Suffix:
Gender:M
Credentials:OD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 N JOHN SIMS PKWY
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:FL
Mailing Address - Zip Code:32580-1005
Mailing Address - Country:US
Mailing Address - Phone:850-678-1722
Mailing Address - Fax:
Practice Address - Street 1:111 N JOHN SIMS PKWY
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:FL
Practice Address - Zip Code:32580-1005
Practice Address - Country:US
Practice Address - Phone:850-678-1722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOP0001109152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL084488800Medicaid
FLT84068Medicare UPIN
FL19125ZMedicare PIN
FL0608190001Medicare NSC