Provider Demographics
NPI:1093735342
Name:LUSICH, PETER L IV (MD)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:L
Last Name:LUSICH
Suffix:IV
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1359
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-0075
Mailing Address - Country:US
Mailing Address - Phone:541-882-1540
Mailing Address - Fax:541-882-2583
Practice Address - Street 1:2865 DAGGETT AVE
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-1106
Practice Address - Country:US
Practice Address - Phone:541-882-6311
Practice Address - Fax:775-883-0797
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NV11770207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology