Healthcare Provider Details

I. General information

NPI: 1104045103
Provider Name (Legal Business Name): PETER URBAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 10/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 N BYRON BUTLER PKWY
PERRY FL
32347-2315
US

IV. Provider business mailing address

555 N BYRON BUTLER PKWY
PERRY FL
32347-2315
US

V. Phone/Fax

Practice location:
  • Phone: 850-584-2778
  • Fax: 850-584-2790
Mailing address:
  • Phone: 850-584-2778
  • Fax: 850-584-2790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1100X
TaxonomyOphthalmic Technician/Technologist
License NumberME0042819
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: