Provider Demographics
NPI:1093773236
Name:LIRA, PETER M
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:M
Last Name:LIRA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 SO ANAHEIM BLVD
Mailing Address - Street 2:SUITE G
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-6218
Mailing Address - Country:US
Mailing Address - Phone:714-635-1401
Mailing Address - Fax:714-635-1422
Practice Address - Street 1:1550 S ANAHEIM BLVD
Practice Address - Street 2:SUITE G
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-6218
Practice Address - Country:US
Practice Address - Phone:562-355-0279
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2011-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACO31561744P3200X
CACO0003156174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACO0003156OtherABC CERTIFICATE
CAX60007611Medicaid
CA6018270001Medicare NSC
CAX60007611Medicaid