Provider Demographics
NPI:1316905631
Name:NEIDENBACH, PETER J (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:J
Last Name:NEIDENBACH
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 1:52 HOSPITAL DR STE 3A
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:NC
Mailing Address - Zip Code:28722-8516
Mailing Address - Country:US
Mailing Address - Phone:828-894-2473
Mailing Address - Fax:828-894-2390
Practice Address - Street 1:52 HOSPITAL DR STE 3A
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:NC
Practice Address - Zip Code:28722-8516
Practice Address - Country:US
Practice Address - Phone:828-894-2473
Practice Address - Fax:828-894-2390
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMMD16384MD207N00000X
NC9501356207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2214227AOtherPTAN
NC9501356OtherSTATE LICENSE
SCMMD16384MDOtherSTATE LICENCE