Provider Demographics
NPI:1396700647
Name:MAYFIELD, PETE IV (MD)
Entity type:Individual
Prefix:
First Name:PETE
Middle Name:
Last Name:MAYFIELD
Suffix:IV
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:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:2051 CLEVIDENCE BLVD
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47129-2278
Practice Address - Country:US
Practice Address - Phone:812-280-9145
Practice Address - Fax:812-280-6641
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY23401207R00000X
IN01034928A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1193576OtherCHA / NCMA
KY64234016Medicaid
004329OtherSIHO - NCMA
KY000023031DOtherHUMANA / NCMA
1166748OtherPASSPORT - NCMA
2440087000OtherPAD - NCMA
IN100097290Medicaid
IN110138280OtherRRMCR - NCMA
KY2533699OtherCIGNA / NCMA
00000062915OtherANTHEM - NCMA
C24838Medicare UPIN
KY64234016Medicaid
KY1361914Medicare PIN