Provider Demographics
NPI:1649231150
Name:SELZER, PETER M (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:M
Last Name:SELZER
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 1:1397 WEIMER RD
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-6253
Mailing Address - Country:US
Mailing Address - Phone:575-751-5872
Mailing Address - Fax:575-751-5869
Practice Address - Street 1:1397 WEIMER RD
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6253
Practice Address - Country:US
Practice Address - Phone:575-751-5871
Practice Address - Fax:575-751-5860
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-01
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM94-3912085R0204X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B56504Medicare UPIN