Provider Demographics
NPI:1194783167
Name:LEMKIN, PETER (OD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:LEMKIN
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 1:110 MED TECH PKWY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-4004
Mailing Address - Country:US
Mailing Address - Phone:423-929-2111
Mailing Address - Fax:423-929-0497
Practice Address - Street 1:110 MED TECH PKWY
Practice Address - Street 2:SUITE 1
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-4004
Practice Address - Country:US
Practice Address - Phone:423-929-2111
Practice Address - Fax:423-929-0497
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD2144152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3944958Medicaid
TN3944959Medicare PIN
TN0284010001Medicare NSC
TNU31547Medicare UPIN
TN0284010002Medicare NSC
TN3944958Medicare PIN