Provider Demographics
NPI:1215134697
Name:BRANT-ZAWADZKI, PETER BOLEK (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:BOLEK
Last Name:BRANT-ZAWADZKI
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:PO BOX 3360
Mailing Address - Street 2:PROVIDENCE HEALTH & SERVICES
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3360
Mailing Address - Country:US
Mailing Address - Phone:866-366-2983
Mailing Address - Fax:
Practice Address - Street 1:1330 ROCKEFELLER
Practice Address - Street 2:STE 520
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-1677
Practice Address - Country:US
Practice Address - Phone:425-297-5200
Practice Address - Fax:425-297-5210
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT54144231205208600000X
WAMD602228932086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8903980Medicare UPIN