Provider Demographics
NPI:1992909311
Name:MENDELSOHN, PETER BRUCE (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:BRUCE
Last Name:MENDELSOHN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:PETER
Other - Middle Name:
Other - Last Name:MENDELSOHN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD, INC
Mailing Address - Street 1:644 MONTEREY BLVD
Mailing Address - Street 2:
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-4546
Mailing Address - Country:US
Mailing Address - Phone:310-560-8806
Mailing Address - Fax:323-296-8673
Practice Address - Street 1:514 N PROSPECT AVE
Practice Address - Street 2:STE 100
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-3036
Practice Address - Country:US
Practice Address - Phone:310-376-2707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-11
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG65308207L00000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG65308Medicare UPIN
CA00G653080Medicare ID - Type UnspecifiedMEDICARE NUMBER