Healthcare Provider Details

I. General information

NPI: 1043661671
Provider Name (Legal Business Name): PETERSON OPTOMETRIC GROUP, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2016
Last Update Date: 06/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4514 OLEANDER DR
WILMINGTON NC
28403-5012
US

IV. Provider business mailing address

4514 OLEANDER DR
WILMINGTON NC
28403-5012
US

V. Phone/Fax

Practice location:
  • Phone: 910-392-4414
  • Fax: 910-392-3153
Mailing address:
  • Phone: 910-392-4414
  • Fax: 910-392-3153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: CAROLINE T PETERSON
Title or Position: OPTOMETRIST
Credential: OD
Phone: 910-392-4414