Provider Demographics
NPI:1366425142
Name:SMITH, PETER CHARLES (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:CHARLES
Last Name:SMITH
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 1:2695 ROCKY MOUNTAIN AVE
Mailing Address - Street 2:STE 150
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-8702
Mailing Address - Country:US
Mailing Address - Phone:970-203-7050
Mailing Address - Fax:970-203-7055
Practice Address - Street 1:2500 ROCKY MOUNTAIN AVE
Practice Address - Street 2:NORTH MEDICAL OFFICE BUILDING
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-9004
Practice Address - Country:US
Practice Address - Phone:970-203-7050
Practice Address - Fax:970-203-7055
Is Sole Proprietor?:No
Enumeration Date:2005-11-25
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO37927207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01620843Medicaid
WY118973500Medicaid
COG93535Medicare UPIN
CO110182841Medicare PIN
CO01620843Medicaid
CO375529YKB8Medicare PIN
WY118973500Medicaid