Provider Demographics
NPI:1447672902
Name:BERGENSKE, PETER (OD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:BERGENSKE
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 1:19710 E BUCKEYE AVE
Mailing Address - Street 2:
Mailing Address - City:OTIS ORCHARDS
Mailing Address - State:WA
Mailing Address - Zip Code:99027-9533
Mailing Address - Country:US
Mailing Address - Phone:509-994-0947
Mailing Address - Fax:
Practice Address - Street 1:19710 E BUCKEYE AVE
Practice Address - Street 2:
Practice Address - City:OTIS ORCHARDS
Practice Address - State:WA
Practice Address - Zip Code:99027-9533
Practice Address - Country:US
Practice Address - Phone:509-994-0947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-16
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00001767152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist