Provider Demographics
NPI:1104321777
Name:MICHALAK, PETER P (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:P
Last Name:MICHALAK
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 1:5055 E BROADWAY BLVD STE A100
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-3629
Mailing Address - Country:US
Mailing Address - Phone:520-327-0460
Mailing Address - Fax:520-795-0225
Practice Address - Street 1:1631 W INA RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-1985
Practice Address - Country:US
Practice Address - Phone:520-585-5738
Practice Address - Fax:520-585-5843
Is Sole Proprietor?:No
Enumeration Date:2018-03-27
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ64431207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ64431OtherAZ LICENSE