Provider Demographics
NPI:1174603047
Name:PETERSON, RENEE LYNN (OD)
Entity type:Individual
Prefix:DR
First Name:RENEE
Middle Name:LYNN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1471 HENDERSONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SANDY LAKE
Mailing Address - State:PA
Mailing Address - Zip Code:16145-3419
Mailing Address - Country:US
Mailing Address - Phone:724-376-3785
Mailing Address - Fax:814-864-0398
Practice Address - Street 1:200 MILLCREEK PLZ
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16565-1102
Practice Address - Country:US
Practice Address - Phone:814-864-4858
Practice Address - Fax:814-864-0398
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPA OEG000497152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA50025OtherDAVIS VISION
PA0075779450002Medicaid
PA084515OtherBLUE CROSS BLUE SHIELD
PA397044OtherNAT'L VISION ADMINISTRATO
PA0075779450002Medicaid
PAU76041Medicare UPIN