Provider Demographics
NPI:1184799108
Name:BARDWICK, PETER ALAN (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:ALAN
Last Name:BARDWICK
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 1:7235 MCCOOL AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-1229
Mailing Address - Country:US
Mailing Address - Phone:424-258-4484
Mailing Address - Fax:310-943-3331
Practice Address - Street 1:2811 WILSHIRE BLVD
Practice Address - Street 2:STE 550
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403
Practice Address - Country:US
Practice Address - Phone:310-828-4759
Practice Address - Fax:310-829-3947
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG34271207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
A45857Medicare UPIN
CAG34271Medicare ID - Type Unspecified