Provider Demographics
NPI:1538233515
Name:STANLEY, PETER GEORGE (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:GEORGE
Last Name:STANLEY
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 1:575 FIFTH ST
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-4623
Mailing Address - Country:US
Mailing Address - Phone:707-263-5181
Mailing Address - Fax:
Practice Address - Street 1:166 D ST
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-5301
Practice Address - Country:US
Practice Address - Phone:707-263-1555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG46859207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G468590Medicaid
CAA50521Medicare UPIN