Provider Demographics
NPI:1225010853
Name:PERUZZO, PETER A (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:A
Last Name:PERUZZO
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 1520
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-3213
Mailing Address - Country:US
Mailing Address - Phone:541-296-9151
Mailing Address - Fax:541-296-9156
Practice Address - Street 1:1620 E 12TH ST
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-3213
Practice Address - Country:US
Practice Address - Phone:541-296-9151
Practice Address - Fax:541-296-9156
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD08964207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR238485Medicaid
OR131228Medicare ID - Type Unspecified
C91276Medicare UPIN
OR238485Medicaid
OR383996Medicare Oscar/Certification