MEDICARE: PETER G THEODOROUS OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OEG000709	PA

General Provider Information

NPI Number	:	1407843535
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PETER G THEODOROUS OD

Provider Business Mailing Address
First Line	:	428 WINDMERE DR
Second Line	:	SUITE 100
City	:	STATE COLLEGE
State	:	PA
Zip	:	16801-7668
Country	:	US
Telephone Number	:	814-234-2015
Fax Number	:	814-238-5300

Provider Business Practice Location Address
First Line	:	4570 PENNS VALLEY RD
Second Line	:	SUITE 3
City	:	SPRING MILLS
State	:	PA
Zip	:	16875-8500
Country	:	US
Telephone Number	:	814-422-8006
Fax Number	:	814-422-8561

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/04/2005
Last Update Date	:	07/08/2007

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