Provider Demographics
NPI:1225018203
Name:PETER, OLUSOJI ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:OLUSOJI
Middle Name:ANTHONY
Last Name:PETER
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 1:11000 S HALSTED ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-3909
Mailing Address - Country:US
Mailing Address - Phone:219-750-9389
Mailing Address - Fax:
Practice Address - Street 1:11000 S HALSTED ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-3909
Practice Address - Country:US
Practice Address - Phone:219-750-9389
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01056426A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200396310Medicaid
IN000000248273OtherANTHEM
IN000000248273OtherANTHEM
IN000000248273OtherANTHEM