Provider Demographics
NPI:1851404743
Name:DAVIS, PETER WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:WILLIAM
Last Name:DAVIS
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:PO BOX 2700
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93438-2700
Mailing Address - Country:US
Mailing Address - Phone:805-736-1253
Mailing Address - Fax:805-736-3193
Practice Address - Street 1:136 N 3RD ST
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-7002
Practice Address - Country:US
Practice Address - Phone:805-736-1253
Practice Address - Fax:805-736-3193
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI39619208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ37313ZMedicaid
WI32415000Medicaid
WI32415000Medicaid
WI000307565Medicare ID - Type Unspecified
CAZZZ37313ZMedicaid