Provider Demographics
NPI:1669568994
Name:BALES, PETER (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:BALES
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:PO BOX 44
Mailing Address - Street 2:
Mailing Address - City:LOOMIS
Mailing Address - State:CA
Mailing Address - Zip Code:95650
Mailing Address - Country:US
Mailing Address - Phone:916-788-8201
Mailing Address - Fax:916-788-8205
Practice Address - Street 1:1613 EUREKA RD
Practice Address - Street 2:SUITE 100
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661
Practice Address - Country:US
Practice Address - Phone:916-788-8201
Practice Address - Fax:916-788-8205
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG63997207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G639970Medicaid
CA00G639972Medicare ID - Type Unspecified
CA00G639970Medicaid