Provider Demographics
NPI:1770561177
Name:NAMNUM, PETER A (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:A
Last Name:NAMNUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8 MENDOTA LN
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SEA RANCH LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33308-2317
Mailing Address - Country:US
Mailing Address - Phone:954-835-0750
Mailing Address - Fax:954-835-0760
Practice Address - Street 1:1600 S ANDREWS AVE
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-2510
Practice Address - Country:US
Practice Address - Phone:954-302-1736
Practice Address - Fax:954-938-9166
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-05
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME61361207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL057408200Medicaid
FL14385WMedicare ID - Type Unspecified
FL057408200Medicaid