Organization
KENNETH A PETERSON
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. KENNETH PETERSON OD (OWNER)
(805) 473-9393
Entity
Organization
Contact information
Practice address
911 OAK PARK BLVD STE 104, PISMO BEACH, CA 93449-3406
(805) 473-9393
Mailing address
911 OAK PARK BLVD STE 104, PISMO BEACH, CA 93449-3406
Taxonomy
Speciality
Code
Description
License number
State
332H00000X
Eyewear Supplier
Primary
CA 9884T
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
OP9884
MEDICARE ID
CA
05
—
SD0098840
—
CA
Enumeration date
03/30/2009
Last updated
03/30/2009
Update your record
If you believe information in your NPPES record is inaccurate, or if you wish to update or deactivate your NPI, you can do so directly with CMS at https://nppes.cms.hhs.gov.
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