Healthcare Provider Details

I. General information

NPI: 1265364814
Provider Name (Legal Business Name): PETER TADROS
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2026
Last Update Date: 05/29/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2388 S ONEIDA ST
ASHWAUBENON WI
54304-5244
US

IV. Provider business mailing address

4001 W EL RANCHO AVE APT A
ORANGE CA
92868-5801
US

V. Phone/Fax

Practice location:
  • Phone: 920-785-5130
  • Fax:
Mailing address:
  • Phone: 248-945-2010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
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: