Provider Demographics
NPI:1760477681
Name:HYUN, PETER S (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:S
Last Name:HYUN
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 1:2120 PROFESSIONAL DR # 135
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-3700
Mailing Address - Country:US
Mailing Address - Phone:916-771-6646
Mailing Address - Fax:
Practice Address - Street 1:2120 PROFESSIONAL DR # 135
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3700
Practice Address - Country:US
Practice Address - Phone:916-771-6646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-113772208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-113772-1Medicaid
ILI39052Medicare UPIN
ILK20027/209384Medicare ID - Type Unspecified