MEDICARE: PETER JOHN KOERNER 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	18003767A	IN
2	152W00000X	Optometrist	1806	SC

General Provider Information

NPI Number	:	1922349836
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PETER JOHN KOERNER O.D.

Provider Business Mailing Address
First Line	:	10110 TWO NOTCH RD
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29223-4383
Country	:	US
Telephone Number	:	803-365-9024
Fax Number	:	803-788-4899

Provider Business Practice Location Address
First Line	:	9741 E WASHINGTON ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46229-3035
Country	:	US
Telephone Number	:	317-869-0975
Fax Number	:

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

Provider Enumeration Date	:	03/04/2013
Last Update Date	:	04/04/2019

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