Provider Demographics
NPI:1215941141
Name:MADILL, PETER VOKES (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:VOKES
Last Name:MADILL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:PETER
Other - Middle Name:
Other - Last Name:MADILL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1020 GRAVENSTEIN HWY. SO.
Mailing Address - Street 2:SUITE 120
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-4569
Mailing Address - Country:US
Mailing Address - Phone:707-823-3312
Mailing Address - Fax:707-823-4901
Practice Address - Street 1:1020 GRAVENSTEIN AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-4569
Practice Address - Country:US
Practice Address - Phone:707-823-3312
Practice Address - Fax:707-823-4901
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA31200207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA26387Medicare UPIN
CA00A312001Medicare ID - Type Unspecified