=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821385865
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IAN PETERS MPH, DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2011
-----------------------------------------------------
Last Update Date | 08/02/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 179 S PARKSIDE DR
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80910-3130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-572-6100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 E LEHIGH AVE SUITE 105
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19125-1012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-707-8483
-----------------------------------------------------
Fax | 215-707-0395
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | DR.0061752
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | OT015344
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------