Provider Demographics
NPI:1366450405
Name:FILLERUP, PETER C
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:C
Last Name:FILLERUP
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1145 E CLARK AVE STE A
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93455-5150
Mailing Address - Country:US
Mailing Address - Phone:805-934-0570
Mailing Address - Fax:805-938-7688
Practice Address - Street 1:1145 E CLARK AVE STE A
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93455-5150
Practice Address - Country:US
Practice Address - Phone:805-934-0570
Practice Address - Fax:805-938-7688
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3665213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT97023Medicare UPIN
CA4101510001Medicare NSC
CAE3665Medicare PIN