Provider Demographics
NPI:1255492393
Name:WILEY, PETER (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:WILEY
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 1:1906 BLAKE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81601-4298
Mailing Address - Country:US
Mailing Address - Phone:970-384-6710
Mailing Address - Fax:970-384-7536
Practice Address - Street 1:1906 BLAKE AVE
Practice Address - Street 2:
Practice Address - City:GLENWOOD SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81601-4298
Practice Address - Country:US
Practice Address - Phone:970-384-6710
Practice Address - Fax:970-384-7536
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2009-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC98007372084P0800X
CO470512084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCO303312Medicare Oscar/Certification
NCG72428Medicare UPIN