Provider Demographics
NPI:1538300157
Name:PICO, PETER LOUIS (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:LOUIS
Last Name:PICO
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 14909
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-0909
Mailing Address - Country:US
Mailing Address - Phone:612-871-1145
Mailing Address - Fax:612-870-5491
Practice Address - Street 1:1973 SLOAN PL STE 100
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55117-2085
Practice Address - Country:US
Practice Address - Phone:612-871-1145
Practice Address - Fax:612-870-5491
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-11
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN52329207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP01233599Medicare PIN