Provider Demographics
NPI:1972615318
Name:WALLENBORN, PETER A III (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:A
Last Name:WALLENBORN
Suffix:III
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 1:285 MCDOWELL ST
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28803-2606
Mailing Address - Country:US
Mailing Address - Phone:828-252-1853
Mailing Address - Fax:828-259-9468
Practice Address - Street 1:285 MCDOWELL ST
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28803-2606
Practice Address - Country:US
Practice Address - Phone:828-252-1853
Practice Address - Fax:828-259-9468
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC27865207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
1070343OtherUNITED HEALTHCARE
NC85517OtherBCBSNC
NC8985517Medicaid
1070343OtherUNITED HEALTHCARE
C86972Medicare UPIN