Provider Demographics
NPI:1699969030
Name:PETERS FAMILY EYECARE ASSOCIATES
Entity type:Organization
Organization Name:PETERS FAMILY EYECARE ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:O.D./OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:L
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-636-3937
Mailing Address - Street 1:219 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:OH
Mailing Address - Zip Code:43506-1759
Mailing Address - Country:US
Mailing Address - Phone:419-636-3937
Mailing Address - Fax:419-636-2302
Practice Address - Street 1:219 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:OH
Practice Address - Zip Code:43506-1759
Practice Address - Country:US
Practice Address - Phone:419-636-3937
Practice Address - Fax:419-636-2302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-29
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4624/T1371152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000139777OtherANTHEM BCBS PIN
OH343703198007OtherMEDICAL MUTUAL OHIO PIN
OH1116050004Medicare NSC
OH343703198007OtherMEDICAL MUTUAL OHIO PIN