Provider Demographics
NPI:1972556918
Name:LALLAS, PETER J (DPM)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:J
Last Name:LALLAS
Suffix:
Gender:M
Credentials:DPM
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 646
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98041-0646
Mailing Address - Country:US
Mailing Address - Phone:425-485-3955
Mailing Address - Fax:
Practice Address - Street 1:12710 TOTEM LAKE BLVD NE
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-2907
Practice Address - Country:US
Practice Address - Phone:425-821-4040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO00000542213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U55920Medicare UPIN