Provider Demographics
NPI:1902801889
Name:LOGERFO, PETER E (MD, PLLC)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:E
Last Name:LOGERFO
Suffix:
Gender:M
Credentials:MD, PLLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11025 CANYON RD E
Mailing Address - Street 2:SUITE A
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-4268
Mailing Address - Country:US
Mailing Address - Phone:253-548-0453
Mailing Address - Fax:253-268-0500
Practice Address - Street 1:11025 CANYON RD E
Practice Address - Street 2:SUITE A
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-4264
Practice Address - Country:US
Practice Address - Phone:253-548-0453
Practice Address - Fax:253-268-0500
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2017-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00036213207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7117492Medicaid
WAGAB15753Medicare PIN
WA7117492Medicaid