Healthcare Provider Details

I. General information

NPI: 1104321777
Provider Name (Legal Business Name): PETER P MICHALAK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2018
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1631 W INA RD
TUCSON AZ
85704-1985
US

IV. Provider business mailing address

4801 E BROADWAY BLVD STE 251
TUCSON AZ
85711-2700
US

V. Phone/Fax

Practice location:
  • Phone: 520-585-5738
  • Fax: 520-585-5843
Mailing address:
  • Phone: 520-327-0460
  • Fax: 520-795-0225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number64431
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: