Provider Demographics
NPI:1396843538
Name:CABALA, PETER (DO)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:CABALA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:557 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BURNS
Mailing Address - State:OR
Mailing Address - Zip Code:97720-1441
Mailing Address - Country:US
Mailing Address - Phone:541-573-7281
Mailing Address - Fax:810-767-7969
Practice Address - Street 1:559 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BURNS
Practice Address - State:OR
Practice Address - Zip Code:97720-1441
Practice Address - Country:US
Practice Address - Phone:541-573-8312
Practice Address - Fax:541-573-8627
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012996207VX0000X
ORDO199989207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1396843538Medicaid
MI114328964Medicaid
MI160B576250OtherBLUE CROSS BLUE SHIELD