Provider Demographics
NPI:1871565788
Name:PETERSON, KENNETH A (OD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:A
Last Name:PETERSON
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 1:911 OAK PARK BLVD STE 104
Mailing Address - Street 2:
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-3406
Mailing Address - Country:US
Mailing Address - Phone:805-473-9393
Mailing Address - Fax:805-473-1974
Practice Address - Street 1:911 OAK PARK BLVD STE 104
Practice Address - Street 2:
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-3406
Practice Address - Country:US
Practice Address - Phone:805-473-9393
Practice Address - Fax:805-473-1974
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-03
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9884T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0098840Medicaid
CA1002290001Medicare NSC
OP9884Medicare ID - Type Unspecified
CASD0098840Medicaid