MEDICARE: DR. PETER S SIEDMAN O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OPC 4066	FL

General Provider Information

NPI Number	:	1548312010
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PETER S SIEDMAN O.D.

Provider Business Mailing Address
First Line	:	7107 LAKE WORTH RD
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33467-2906
Country	:	US
Telephone Number	:	561-966-2212
Fax Number	:	561-966-2215

Provider Business Practice Location Address
First Line	:	7107 LAKE WORTH RD
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33467-2906
Country	:	US
Telephone Number	:	561-966-2212
Fax Number	:	561-966-2215

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/17/2007
Last Update Date	:	07/08/2007

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