Provider Demographics
NPI:1720081136
Name:DZIAD, PETER M (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:M
Last Name:DZIAD
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 1:95 S PAGOSA BLVD
Mailing Address - Street 2:
Mailing Address - City:PAGOSA SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81147-8329
Mailing Address - Country:US
Mailing Address - Phone:970-731-3700
Mailing Address - Fax:970-731-0504
Practice Address - Street 1:95 S PAGOSA BLVD
Practice Address - Street 2:
Practice Address - City:PAGOSA SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81147-8329
Practice Address - Country:US
Practice Address - Phone:970-731-3700
Practice Address - Fax:970-731-0504
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2015-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35051892D208600000X
CODR.0051648208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000500815OtherANTHEM
OH00160OtherPARAMOUNT
20-82460OtherUHC
297443892-005OtherMMO
4044721OtherAETNA
MI5189177Medicaid
OHP00389820OtherRRMC
OH0665696Medicaid
OH$$$$$$$$$-00OtherBWC
$$$$$$$$$-009OtherMMO
4044721OtherAETNA
297443892-005OtherMMO
20-82460OtherUHC
OH0612162Medicare PIN