Provider Demographics
NPI:1356345789
Name:UZELAC, PETER S (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:S
Last Name:UZELAC
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 1:1100 S ELISEO DR STE 107
Mailing Address - Street 2:ATTN: JAIMIE VIGIL
Mailing Address - City:GREENBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94904-2017
Mailing Address - Country:US
Mailing Address - Phone:415-925-9404
Mailing Address - Fax:415-484-7045
Practice Address - Street 1:1100 S ELISEO DR STE 107
Practice Address - Street 2:ATTN: JAIMIE VIGIL
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904-2017
Practice Address - Country:US
Practice Address - Phone:415-925-9404
Practice Address - Fax:415-484-7045
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA72448207VE0102X
KY40105207VE0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY50011330OtherPASSPORT SPECIALITY PSC
KY50011331OtherPASSPORT SPECIALITY- FOUNDATION
KY50011332OtherPASSPORT PCP FOUNDATION
IN200878600Medicaid
KY64120736Medicaid
KY000000480316OtherANTHEM PSC
KY50011332OtherPASSPORT PCP FOUNDATION
KY0722532Medicare PIN
IN200878600Medicaid