Provider Demographics
NPI:1225097207
Name:PETERS, PAUL LEON (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:LEON
Last Name:PETERS
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 1:419 S WASHINGTON ST
Mailing Address - Street 2:STE 101
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601
Mailing Address - Country:US
Mailing Address - Phone:307-265-1620
Mailing Address - Fax:307-237-1074
Practice Address - Street 1:419 S WASHINGTON ST
Practice Address - Street 2:STE 101
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601
Practice Address - Country:US
Practice Address - Phone:307-265-1620
Practice Address - Fax:307-237-1074
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY4089A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY10341700Medicaid
360003250OtherRAILROAD MEDICARE
WY10341700Medicaid
A73111Medicare UPIN