Provider Demographics
NPI:1902291644
Name:WALLER, PETER J (DO)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:J
Last Name:WALLER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:9650 GROSS POINT RD. SUITE 2900
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076
Mailing Address - Country:US
Mailing Address - Phone:847-866-7846
Mailing Address - Fax:224-251-2905
Practice Address - Street 1:9650 GROSS POINT RD. SUITE 2900
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076
Practice Address - Country:US
Practice Address - Phone:847-866-7846
Practice Address - Fax:224-251-2905
Is Sole Proprietor?:No
Enumeration Date:2015-03-31
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036150318207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine