Provider Demographics
NPI:1821042334
Name:ANGLETON, PETER JOHN (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:JOHN
Last Name:ANGLETON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:PETER
Other - Middle Name:JOHN
Other - Last Name:ANGLETON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2963 E COPPER POINT DR
Mailing Address - Street 2:SUITE 150
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-9055
Mailing Address - Country:US
Mailing Address - Phone:208-322-1730
Mailing Address - Fax:208-322-1731
Practice Address - Street 1:1055 N CURTIS RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1352
Practice Address - Country:US
Practice Address - Phone:208-322-1730
Practice Address - Fax:208-322-1731
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2017-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD183357207P00000X
IDM5573207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID004026000Medicaid
E04238Medicare UPIN
ID1122336Medicare ID - Type Unspecified