Provider Demographics
NPI:1700968344
Name:MJOS, PETER O (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:O
Last Name:MJOS
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 196276
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99519-6276
Mailing Address - Country:US
Mailing Address - Phone:907-212-6522
Mailing Address - Fax:
Practice Address - Street 1:3300 PROVIDENCE DR
Practice Address - Street 2:SUITE B314
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4690
Practice Address - Country:US
Practice Address - Phone:907-212-3420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1553207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD15151Medicaid
AK162616OtherMEDICARE MD GROUP #
AK162616OtherMEDICARE MD GROUP #
AKC97178Medicare UPIN
AKMD15151Medicaid