MEDICARE: DR. PETER O. LUCIA 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	1594	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0484250001	OTHER	MN	DMERC
2	69467LU	OTHER	MN	BLUECROSS

General Provider Information

NPI Number	:	1669543781
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PETER O. LUCIA O.D.

Provider Business Mailing Address
First Line	:	302 E HOWARD ST
Second Line	:
City	:	HIBBING
State	:	MN
Zip	:	55746-1772
Country	:	US
Telephone Number	:	218-263-8233
Fax Number	:	218-263-4561

Provider Business Practice Location Address
First Line	:	302 E HOWARD ST
Second Line	:
City	:	HIBBING
State	:	MN
Zip	:	55746-1772
Country	:	US
Telephone Number	:	218-263-8233
Fax Number	:	218-263-4561

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

Provider Enumeration Date	:	11/11/2006
Last Update Date	:	07/08/2007

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