Provider Demographics
NPI:1679571624
Name:SIMONIAN, PETER T (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:T
Last Name:SIMONIAN
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:PO BOX 28921
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93729-8921
Mailing Address - Country:US
Mailing Address - Phone:559-228-4200
Mailing Address - Fax:559-224-3920
Practice Address - Street 1:6121 N THESTA ST
Practice Address - Street 2:SUITE 114
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-8603
Practice Address - Country:US
Practice Address - Phone:559-439-7633
Practice Address - Fax:559-439-7631
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G837730Medicare ID - Type UnspecifiedMEDICARE ID
CAG55317Medicare UPIN