1356345789 NPI number — PETER S UZELAC M.D.

Table of content: PETER S UZELAC M.D. (NPI 1356345789)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356345789 NPI number — PETER S UZELAC M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
UZELAC
Provider First Name:
PETER
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356345789
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/05/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1100 S ELISEO DR STE 107
Provider Second Line Business Mailing Address:
ATTN: JAIMIE VIGIL
Provider Business Mailing Address City Name:
GREENBRAE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94904-2017
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
415-925-9404
Provider Business Mailing Address Fax Number:
415-484-7045

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 S ELISEO DR STE 107
Provider Second Line Business Practice Location Address:
ATTN: JAIMIE VIGIL
Provider Business Practice Location Address City Name:
GREENBRAE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94904-2017
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
415-925-9404
Provider Business Practice Location Address Fax Number:
415-484-7045
Provider Enumeration Date:
06/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207VE0102X , with the licence number:  A72448 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 50011330 . This is a "PASSPORT SPECIALITY PSC" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 50011331 . This is a "PASSPORT SPECIALITY- FOUNDATION" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 50011332 . This is a "PASSPORT PCP FOUNDATION" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 200878600 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 64120736 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000480316 . This is a "ANTHEM PSC" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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