Individual
TIMOTHY A PETERS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1919 LAKE AVE, SUITE 104, PLYMOUTH, IN 46563-7830
(574) 941-2929
(574) 941-3008
Mailing address
PO BOX 6309, SOUTH BEND, IN 46660-6309
(574) 335-8700
(574) 335-0760
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
01043381
IN
207R00000X
Internal Medicine Physician
01043381
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000216162
BCBS
IN
01
—
000000659776
BCBS
IN
05
—
100380540
—
IN
05
—
100380540A
—
IN
Enumeration date
06/29/2006
Last updated
05/08/2015
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