Provider Demographics
NPI:1679647838
Name:LOISIDES, PETER MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:MICHAEL
Last Name:LOISIDES
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 1:2001 SANTA MONICA BLVD
Mailing Address - Street 2:SUITE 590W
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2102
Mailing Address - Country:US
Mailing Address - Phone:310-829-0039
Mailing Address - Fax:310-828-1791
Practice Address - Street 1:2001 SANTA MONICA BLVD
Practice Address - Street 2:SUITE 590W
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2102
Practice Address - Country:US
Practice Address - Phone:310-829-0039
Practice Address - Fax:310-828-1791
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG72821208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
F86870Medicare UPIN
G72821Medicare PIN