Provider Demographics
NPI:1134394430
Name:HEADLEY, PETER ABRAHAM (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:ABRAHAM
Last Name:HEADLEY
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 1:4901 LANG AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4397
Mailing Address - Country:US
Mailing Address - Phone:505-842-8171
Mailing Address - Fax:505-246-0684
Practice Address - Street 1:610 BROADWAY BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2372
Practice Address - Country:US
Practice Address - Phone:505-242-3991
Practice Address - Fax:505-243-8405
Is Sole Proprietor?:No
Enumeration Date:2008-04-28
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2013-0794208800000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMMD2013-0794OtherMEDICAL LICENSE
NM6305351Medicaid