Provider Demographics
NPI:1629083407
Name:JURISICH, PETER DANIEL (DO)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:DANIEL
Last Name:JURISICH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 MEDICAL PLAZA DR STE 175
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-3049
Mailing Address - Country:US
Mailing Address - Phone:916-782-2146
Mailing Address - Fax:
Practice Address - Street 1:2 MEDICAL PLAZA DR STE 175
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3049
Practice Address - Country:US
Practice Address - Phone:916-782-2146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8542207RC0001X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX85420Medicaid
CA1671625OtherGREAT WEST
CA7450546OtherAETNA
CA020A85420OtherBLUE SHIELD
CA2361104OtherUNITED HEALTHCARE
CA4911481OtherCIGNA
CA95883OtherINTERPLAN
CA2121684OtherFIRST HEALTH
CA90136861OtherPACIFICARE
CA000810778930OtherPHCS
CA102287OtherHEALTH NET
CA20A542OtherBLUE CROSS
CA7450546OtherAETNA
H88494Medicare UPIN
CA4911481OtherCIGNA