Provider Demographics
NPI:1427062439
Name:MEDVED, PETER MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:MICHAEL
Last Name:MEDVED
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 1:9200 W LOOMIS RD
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53132-8887
Mailing Address - Country:US
Mailing Address - Phone:414-529-9330
Mailing Address - Fax:414-529-9331
Practice Address - Street 1:9200 W LOOMIS RD
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:WI
Practice Address - Zip Code:53132-8887
Practice Address - Country:US
Practice Address - Phone:414-529-9330
Practice Address - Fax:414-529-9331
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI24579207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30756000Medicaid
WI24579OtherSTATE LICENSE #
WIAM1769768OtherDEA#
WI01575-0001Medicare ID - Type Unspecified
WI30756000Medicaid