Provider Demographics
NPI:1245289263
Name:JIANG, PETER P (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:P
Last Name:JIANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3170 COUNTY ROAD 635
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-8656
Mailing Address - Country:US
Mailing Address - Phone:573-334-6202
Mailing Address - Fax:
Practice Address - Street 1:211 SAINT FRANCIS DR
Practice Address - Street 2:SPECIALTY CLINIC
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-5049
Practice Address - Country:US
Practice Address - Phone:573-331-5932
Practice Address - Fax:573-331-5931
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005023732207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO199929OtherBLUE SHIELD/BLUE CHOICE
MO200307908Medicaid
MO718095OtherHEALTHLINK
MOP00440876Medicare UPIN
MO199929OtherBLUE SHIELD/BLUE CHOICE
MO935111444Medicare PIN
I40487Medicare UPIN
MOP00272375Medicare PIN