Provider Demographics
NPI:1366631525
Name:BROEKELSCHEN, PETER (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:BROEKELSCHEN
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 1:1441 AVOCADO AVE STE 607
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7707
Mailing Address - Country:US
Mailing Address - Phone:949-759-1042
Mailing Address - Fax:949-759-0143
Practice Address - Street 1:1441 AVOCADO AVE STE 607
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7707
Practice Address - Country:US
Practice Address - Phone:949-759-1042
Practice Address - Fax:949-759-0143
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA25076207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA24275Medicare UPIN
WA25076AMedicare PIN