Provider Demographics
NPI:1114088796
Name:DISALVO, PETER (OD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:DISALVO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2624 KNOLLS DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-8302
Mailing Address - Country:US
Mailing Address - Phone:510-684-7788
Mailing Address - Fax:707-526-2032
Practice Address - Street 1:2320 MIDWAY DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-5017
Practice Address - Country:US
Practice Address - Phone:707-526-2020
Practice Address - Fax:707-526-2032
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2021-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA5653T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0056530Medicaid