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General NPI Number Information
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NPI Number | 1972607323
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Entity Type | Individual
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Provider Name | BERT M PETERSON JR. O.D.
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Gender | Male
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Dates
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Enumeration Date | 09/07/2006
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Last Update Date | 07/18/2018
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Provider Practice Location Address
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Address Line | 1126 E. LYNCHBURG-SALEM TPK WALMART VISION CENTER
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City | BEDFORD
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State | VA
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Zip | 24523-3446
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Country | US
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Telephone | 540-586-0111
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Fax | 540-586-0111
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Provider Business Mailing Address
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Address Line | PO BOX 823
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City | BEDFORD
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State | VA
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Zip | 24523-0823
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Country | US
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Telephone | 540-586-0111
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Fax | 540-586-0111
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 0618000348
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License Number State | VA
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