Provider Demographics
NPI:1982644233
Name:SULTANA, PETER
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:SULTANA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1551 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-3568
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:707-303-4377
Practice Address - Street 1:1551 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-3568
Practice Address - Country:US
Practice Address - Phone:707-586-5555
Practice Address - Fax:707-303-4377
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA71229207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
00A712290Medicare ID - Type UnspecifiedTEAMHEALTH
CAH15372Medicare UPIN
00A712291Medicare ID - Type UnspecifiedOFFICE