Provider Demographics
NPI:1750339883
Name:VISTA, JEFF PETER (MD)
Entity type:Individual
Prefix:DR
First Name:JEFF
Middle Name:PETER
Last Name:VISTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 ARDEN CREST CT
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27513-3831
Mailing Address - Country:US
Mailing Address - Phone:919-867-1134
Mailing Address - Fax:
Practice Address - Street 1:2301 ERWIN RD DUMC 3096
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27710-3108
Practice Address - Country:US
Practice Address - Phone:919-681-0196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP1707207P00000X
NC2013-00066207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM42572070Medicaid
TX300347703Medicaid
TX313800YKN5Medicare PIN
NM42572070Medicaid