Healthcare Provider Details

I. General information

NPI: 1821084328
Provider Name (Legal Business Name): CYNTHIA L PEETERSE OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 12/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 EGLIN PKWY
SHALIMAR FL
32579-1245
US

IV. Provider business mailing address

1201 EGLIN PKWY
SHALIMAR FL
32579-1245
US

V. Phone/Fax

Practice location:
  • Phone: 850-613-6588
  • Fax: 850-613-6574
Mailing address:
  • Phone: 850-613-6588
  • Fax: 850-613-6574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number0B3056
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: