Provider Demographics
NPI:1114947751
Name:WYZINSKI, PETER (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:WYZINSKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10888
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97440-2888
Mailing Address - Country:US
Mailing Address - Phone:541-343-5000
Mailing Address - Fax:541-344-9478
Practice Address - Street 1:1125 DARLENE LN
Practice Address - Street 2:SUITE 100
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-1601
Practice Address - Country:US
Practice Address - Phone:541-343-5000
Practice Address - Fax:541-344-9478
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD14320207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR143115Medicaid
OR012381-0004OtherPACIFICARE/SECURE HORIZON
OR012381-0004OtherPACIFICARE/SECURE HORIZON
ORR109586Medicare PIN