Healthcare Provider Details

I. General information

NPI: 1194783167
Provider Name (Legal Business Name): PETER LEMKIN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 01/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 MED TECH PKWY SUITE 1
JOHNSON CITY TN
37604-4004
US

IV. Provider business mailing address

110 MED TECH PKWY SUITE 1
JOHNSON CITY TN
37604-4004
US

V. Phone/Fax

Practice location:
  • Phone: 423-929-2111
  • Fax: 423-929-0497
Mailing address:
  • Phone: 423-929-2111
  • Fax: 423-929-0497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD2144
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: