Provider Demographics
NPI:1710984331
Name:PELIKAN, PETER C (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:C
Last Name:PELIKAN
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 280W
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2102
Mailing Address - Country:US
Mailing Address - Phone:310-829-7678
Mailing Address - Fax:310-829-6889
Practice Address - Street 1:2001 SANTA MONICA BLVD STE 280W
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2172
Practice Address - Country:US
Practice Address - Phone:310-829-7678
Practice Address - Fax:310-829-6889
Is Sole Proprietor?:No
Enumeration Date:2005-06-29
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG43904207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA92448Medicare UPIN