Healthcare Provider Details

I. General information

NPI: 1114088796
Provider Name (Legal Business Name): PETER DISALVO OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 03/27/2021
Certification Date: 03/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2320 MIDWAY DR
SANTA ROSA CA
95405-5017
US

IV. Provider business mailing address

2624 KNOLLS DR
SANTA ROSA CA
95405-8302
US

V. Phone/Fax

Practice location:
  • Phone: 707-526-2020
  • Fax: 707-526-2032
Mailing address:
  • Phone: 510-684-7788
  • Fax: 707-526-2032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberCA5653T
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: