1194709246 NPI number — DR. PETER JOHN MIOTTO M.D.

Table of content: DR. PETER JOHN MIOTTO M.D. (NPI 1194709246)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194709246 NPI number — DR. PETER JOHN MIOTTO M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MIOTTO
Provider First Name:
PETER
Provider Middle Name:
JOHN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194709246
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
159 UNION ST
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
MARLBOROUGH
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01752-1274
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-229-3640
Provider Business Mailing Address Fax Number:
508-229-7954

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
159 UNION ST
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
MARLBOROUGH
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01752-1274
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-229-3640
Provider Business Practice Location Address Fax Number:
508-229-7954
Provider Enumeration Date:
12/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  203288 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0130851 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 203288 . This is a "TUFTS HEALTH PLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 61677 . This is a "FALLON COMMUNITY HEALTH" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 808067 . This is a "HARVARD PILGRIM HEALTH CA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 203288 . This is a "MA STATE LICENSE" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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