Provider Demographics
NPI:1568015253
Name:KIRIAKOS, PETER JOHN III
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:JOHN
Last Name:KIRIAKOS
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31760 CASINO DR
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-2313
Mailing Address - Country:US
Mailing Address - Phone:951-471-4600
Mailing Address - Fax:951-471-4623
Practice Address - Street 1:31760 CASINO DR
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-2313
Practice Address - Country:US
Practice Address - Phone:951-471-4600
Practice Address - Fax:951-471-4623
Is Sole Proprietor?:No
Enumeration Date:2019-07-22
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0Medicaid