Objective: Pedestrians comprise 78% of the road fatalities in Peru. The objective of this study was to explore the relationship between the walking environment and pedestrian–motor vehicle collisions. Methods: A matched case-control study was used to detect the odds of a pedestrian–motor vehicle collision at a pedestrian crossing location. Data were collected from 11 sampled police commissaries in Lima, Peru. Results: In a multivariable model adjusting for vehicle and pedestrian flow, pedestrian collisions were less likely in the presence of a curb and sidewalk on both roadway sides (odds ratio [OR] = 0.19, 95% confidence interval [CI], 0.11–0.33) or a pedestrian barricade (OR = 0.11, 95% CI, 0.01–0.81). There was a greater risk of collisions for each street vendor present (OR = 2.82, 95% CI, 1.59–5.00) or whether any parked vehicles (OR = 3.67, 95% CI, 1.18–11.4) were present. Conclusions: Improving or addressing these potentially modifiable features of the walking environment could improve pedestrian safety in Lima and in similar urban settings in low- and middle-income countries.