Healthcare Provider Details

I. General information

NPI: 1477987741
Provider Name (Legal Business Name): BRIAN MICHAEL PETERSON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2013
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 W GRANADA BLVD STE 1
ORMOND BEACH FL
32174-5941
US

IV. Provider business mailing address

1857 OLD TOMOKA RD W
ORMOND BEACH FL
32174-6704
US

V. Phone/Fax

Practice location:
  • Phone: 386-675-6599
  • Fax:
Mailing address:
  • Phone: 386-986-7997
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC 4830
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: