Provider Demographics
NPI:1265637227
Name:BANGSUND, PETER J (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:J
Last Name:BANGSUND
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 1:111 RALEY BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95928-8351
Mailing Address - Country:US
Mailing Address - Phone:530-894-8800
Mailing Address - Fax:530-894-8929
Practice Address - Street 1:111 RALEY BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95928-8351
Practice Address - Country:US
Practice Address - Phone:530-894-8800
Practice Address - Fax:530-894-8929
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-19
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR8077207R00000X
CAA123857207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1265637227Medicare NSC