Provider Demographics
NPI:1518052794
Name:DRISCOLL, PETER L (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:L
Last Name:DRISCOLL
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:PO BOX 26666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-6770
Mailing Address - Fax:
Practice Address - Street 1:121 EL PASO RD
Practice Address - Street 2:LINCOLN COUNTY MEDICAL COMPLEX
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345-6033
Practice Address - Country:US
Practice Address - Phone:575-630-8350
Practice Address - Fax:575-630-5232
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM86034208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM37044Medicaid
341328704Medicare PIN
D35601Medicare UPIN