Provider Demographics
NPI:1366965675
Name:STACH, PETER (DPM)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:STACH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4770 SW WATSON AVE
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-0511
Mailing Address - Country:US
Mailing Address - Phone:503-805-4720
Mailing Address - Fax:971-223-0969
Practice Address - Street 1:4770 SW WATSON AVE
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-0511
Practice Address - Country:US
Practice Address - Phone:503-805-4720
Practice Address - Fax:971-223-0969
Is Sole Proprietor?:No
Enumeration Date:2017-07-18
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORDP198085213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500798722Medicaid