Provider Demographics
NPI:1033166905
Name:LOSEV, PETER (C PED)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:LOSEV
Suffix:
Gender:M
Credentials:C PED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1622 WEBSTER ST
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-2134
Mailing Address - Country:US
Mailing Address - Phone:510-523-4316
Mailing Address - Fax:
Practice Address - Street 1:1622 WEBSTER ST
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-2134
Practice Address - Country:US
Practice Address - Phone:510-523-4316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-27
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3265171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADME02996FMedicaid
CA1237660001Medicare ID - Type Unspecified