Provider Demographics
NPI:1134110828
Name:VANN, PETER WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:WILLIAM
Last Name:VANN
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 1:9144 S DROMEDARY DR
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-3001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2000 W BETHANY HOME RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-2443
Practice Address - Country:US
Practice Address - Phone:602-249-0212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13430207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ453051001OtherGROUP HEALTH
AZ078908Medicaid
AZ860373636OtherHUMANA
AZAW1436OtherHEALTHNET
AZ3981220OtherEYECARE
AZAZ0728670OtherBLUE CROSS/BLUE SHIELD
AZ28216Medicare PIN
AZAZ0728670OtherBLUE CROSS/BLUE SHIELD