Provider Demographics
NPI:1104939339
Name:PETERSON, AMY L (OD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:PETERSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:L
Other - Last Name:CORBIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 500
Mailing Address - Street 2:324 MAIN ST
Mailing Address - City:SAXONBURG
Mailing Address - State:PA
Mailing Address - Zip Code:16056
Mailing Address - Country:US
Mailing Address - Phone:724-352-2433
Mailing Address - Fax:724-352-8466
Practice Address - Street 1:324 MAIN ST
Practice Address - Street 2:
Practice Address - City:SAXONBURG
Practice Address - State:PA
Practice Address - Zip Code:16056
Practice Address - Country:US
Practice Address - Phone:724-352-2433
Practice Address - Fax:724-352-8466
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000390152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01939063Medicaid
PA6084930001Medicare NSC
PA060655XQMMedicare PIN
PA01939063Medicaid