Provider Demographics
NPI:1720188477
Name:PETERS, CANDY L (MD)
Entity Type:Individual
Prefix:DR
First Name:CANDY
Middle Name:L
Last Name:PETERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:CANDY
Other - Middle Name:L P
Other - Last Name:VORDERBRUG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1600 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:LOVINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:88260
Mailing Address - Country:US
Mailing Address - Phone:575-396-6611
Mailing Address - Fax:
Practice Address - Street 1:1600 MAIN STREET
Practice Address - Street 2:
Practice Address - City:LOVINGTON
Practice Address - State:NM
Practice Address - Zip Code:88260-2871
Practice Address - Country:US
Practice Address - Phone:575-396-6611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-23
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI42413207Q00000X
NMMD2020-0642207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI434T0VOOtherBLUE CROSS BLUE SHIELD
WI33343300Medicaid
MI4595645Medicaid
MI4595645Medicaid
G95068Medicare UPIN