Basic Information
| Provider Information | |||||||||
| NPI: | 1679633507 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | QUIROS | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 800 FAIRMOUNT AVE | ||||||||
| Address2: | SUITE 215 | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911053150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6268174701 | ||||||||
| FaxNumber: | 6268174702 | ||||||||
| Practice Location | |||||||||
| Address1: | 625 S FAIR OAKS AVE | ||||||||
| Address2: | SUITE 280 | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911052613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6268174747 | ||||||||
| FaxNumber: | 6268174748 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2006 | ||||||||
| LastUpdateDate: | 01/16/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | A64488 | CA | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 00A644880 | 01 | CA | BLUE SHIELD | OTHER | W11993 | 01 | CA | MEDICARE GROUP# LA OFFICE | OTHER | 00A644880 | 05 | CA | MEDICAID | 180040554 | 01 | CA | MEDICARE RAILROAD | OTHER | W11993A | 01 | CA | MEDICARE GRP# ORANGE OFF | OTHER | ZZZ51610Z | 01 | CA | MEDICARE GRP# PALM SPRING | OTHER |