Provider Demographics
NPI:1750314662
Name:DEGOLIA, PETER ALEXANDER (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:ALEXANDER
Last Name:DEGOLIA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:PETER
Other - Middle Name:A
Other - Last Name:DEGOLIA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD CMD
Mailing Address - Street 1:3605 WARRENSVILLE CENTER RD
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:SHAKER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44122
Mailing Address - Country:US
Mailing Address - Phone:216-286-6295
Mailing Address - Fax:216-286-6341
Practice Address - Street 1:11100 EUCLID AVENUE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106
Practice Address - Country:US
Practice Address - Phone:216-844-3944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35062016207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0968243Medicaid
OH738457OtherBUCKEYE
OH000000221407OtherUNISON
OH414960OtherWELLCARE
OH000000531122OtherANTHEM
OHP00412320OtherRAILROAD MEDICARE
OH4558739OtherAETNA
OHDE0766053Medicare PIN
OH000000221407OtherUNISON
OH414960OtherWELLCARE