Provider Demographics
NPI:1528156015
Name:COL, PETER RAYMOND (OD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:RAYMOND
Last Name:COL
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:PO BOX 730
Mailing Address - Street 2:
Mailing Address - City:PINE GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95665-0730
Mailing Address - Country:US
Mailing Address - Phone:209-296-5565
Mailing Address - Fax:209-296-3323
Practice Address - Street 1:13828 GOLD MINE RD STE 2
Practice Address - Street 2:
Practice Address - City:PINE GROVE
Practice Address - State:CA
Practice Address - Zip Code:95665-9494
Practice Address - Country:US
Practice Address - Phone:209-296-5565
Practice Address - Fax:209-296-3323
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 6634 TPG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0066340Medicaid
CASD0066340Medicare ID - Type Unspecified
CAT10379Medicare UPIN