Provider Demographics
NPI:1942289996
Name:FRIES, PETER D (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:D
Last Name:FRIES
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 1:777 TANGLEFOOT LN
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-1650
Mailing Address - Country:US
Mailing Address - Phone:563-323-2020
Mailing Address - Fax:563-328-5694
Practice Address - Street 1:777 TANGLEFOOT LN
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722
Practice Address - Country:US
Practice Address - Phone:563-323-2020
Practice Address - Fax:563-328-5694
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036082456207W00000X, 207WX0200X
IA28136207WX0200X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL790730OtherIL GROUP MEDICARE
IA0084467Medicaid
IA0060350OtherIA GROUP MEDICAID
IA26568OtherIA GROUP MEDICARE
IA26568OtherIA GROUP MEDICARE
IL790730OtherIL GROUP MEDICARE
IA0084467Medicaid