Healthcare Provider Details

I. General information

NPI: 1750314662
Provider Name (Legal Business Name): PETER ALEXANDER DEGOLIA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: PETER A DEGOLIA MD CMD

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 03/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11100 EUCLID AVENUE
CLEVELAND OH
44106
US

IV. Provider business mailing address

3605 WARRENSVILLE CENTER RD 1ST FLOOR
SHAKER HEIGHTS OH
44122
US

V. Phone/Fax

Practice location:
  • Phone: 216-844-3944
  • Fax:
Mailing address:
  • Phone: 216-286-6295
  • Fax: 216-286-6341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number35062016
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: