1104838010 NPI number — PETER JOHN GEORGIO D.D.S

Table of content: PETER JOHN GEORGIO D.D.S (NPI 1104838010)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104838010 NPI number — PETER JOHN GEORGIO D.D.S

Organization/Personal Information

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

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GEORGIO
Provider Other First Name:
PETER
Provider Other Middle Name:
JOHN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.D.S
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1104838010
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2263 W BIRCH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRESNO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93711-0442
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
559-431-8515
Provider Business Mailing Address Fax Number:
559-227-2880

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16835 ALKALI DR
Provider Second Line Business Practice Location Address:
SUITE M
Provider Business Practice Location Address City Name:
LEMOORE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93245-9463
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-924-0460
Provider Business Practice Location Address Fax Number:
559-924-2197
Provider Enumeration Date:
08/12/2006

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: 1223D0001X , with the licence number:  CA26640 , 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: 26640 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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