Provider Demographics
NPI:1578598488
Name:THOM, PETER A (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:A
Last Name:THOM
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:405 TRAFFIC WAY
Mailing Address - Street 2:SUITE A
Mailing Address - City:ARROYO GRANDE
Mailing Address - State:CA
Mailing Address - Zip Code:93420-3346
Mailing Address - Country:US
Mailing Address - Phone:805-481-4202
Mailing Address - Fax:805-481-0223
Practice Address - Street 1:405 TRAFFIC WAY
Practice Address - Street 2:SUITE A
Practice Address - City:ARROYO GRANDE
Practice Address - State:CA
Practice Address - Zip Code:93420-3346
Practice Address - Country:US
Practice Address - Phone:805-481-4202
Practice Address - Fax:805-481-0223
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2015-01-26
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Provider Licenses
StateLicense IDTaxonomies
CAG39102207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G391020Medicaid
CA00G391020Medicaid
CAG39102Medicare PIN