Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223S0112X | Oral and Maxillofacial Surgeon | 5846 | WI |
Y | 1223S0112X | Oral and Maxillofacial Surgeon | D12064 | MN |
NPI | 1104976570 |
---|---|
Provider Name | Peter J Mayer |
First Address | Duluth, MN 55811-4046 |
Second Address | Duluth, MN 55811-4046 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/01/2007 |
Last Update Date | 05/03/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
336G1MA | MINNESOTA BCBS (01) | MN |
33793800 | WISCONSIN MEDICAID (01) | WI |
V07680 | (02) | MN |