1770783011 NPI number — PETER Y SIROKA DPM PC

Table of content: (NPI 1770783011)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770783011 NPI number — PETER Y SIROKA DPM PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PETER Y SIROKA DPM PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1770783011
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/31/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1450 WASHINGTON BLVD
Provider Second Line Business Mailing Address:
1ST FLOOR
Provider Business Mailing Address City Name:
STAMFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06902-2451
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-327-9321
Provider Business Mailing Address Fax Number:
203-967-2140

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1275 SUMMER ST STE 106
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STAMFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06905-5315
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-614-8185
Provider Business Practice Location Address Fax Number:
203-614-8186
Provider Enumeration Date:
07/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SIROKA
Authorized Official First Name:
PETER
Authorized Official Middle Name:
Y
Authorized Official Title or Position:
DPM PC
Authorized Official Telephone Number:
203-614-8185

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  N003988-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 56030000334CT1 . This is a "ANTHEM BCBS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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