Provider Demographics
NPI:1588655096
Name:WALLSKOG, PETER A (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:A
Last Name:WALLSKOG
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 1:2637 MIDPOINT DR STE B
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-4408
Mailing Address - Country:US
Mailing Address - Phone:970-488-1666
Mailing Address - Fax:
Practice Address - Street 1:2637 MIDPOINT DR STE B
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-4408
Practice Address - Country:US
Practice Address - Phone:970-488-1666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0054454207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO381333YT22Medicare PIN
CO381333YT22Medicare PIN
CO00830267Medicaid
COP01405365OtherRR MEDICARE