Provider Demographics
NPI:1952363780
Name:OBLIGATO, PETER RICHARD (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:RICHARD
Last Name:OBLIGATO
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 1:3609 E LOOKOUT DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-7916
Mailing Address - Country:US
Mailing Address - Phone:208-772-5860
Mailing Address - Fax:208-762-3707
Practice Address - Street 1:700 W IRONWOOD DR STE 170E
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2666
Practice Address - Country:US
Practice Address - Phone:208-292-0990
Practice Address - Fax:208-292-2950
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG27958207P00000X
IDM6042207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G27958OtherBLUE CROSS
00G279580OtherMEDI CAL
00G279580OtherBLUE SHIELD
010039635OtherRAILROAD MEDICARE
CA00G279580Medicaid
00G279580OtherMEDI CAL
00G279580OtherBLUE SHIELD
ID1369049Medicare PIN
G27958OtherBLUE CROSS