Provider Demographics
NPI:1750497160
Name:DAVANZO, PETER A (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:A
Last Name:DAVANZO
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 1:940 WEST PORT PLAZA
Mailing Address - Street 2:STE 270
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146
Mailing Address - Country:US
Mailing Address - Phone:314-453-0600
Mailing Address - Fax:314-453-0083
Practice Address - Street 1:350 SPARTA AVE
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:NJ
Practice Address - Zip Code:07871-1150
Practice Address - Country:US
Practice Address - Phone:973-729-8588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA050074207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E27383Medicare UPIN
NJ577739ST3Medicare ID - Type Unspecified