Healthcare Provider Details

I. General information

NPI: 1194709246
Provider Name (Legal Business Name): PETER JOHN MIOTTO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/02/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 UNION ST SUITE 104
MARLBOROUGH MA
01752-1274
US

IV. Provider business mailing address

159 UNION ST SUITE 104
MARLBOROUGH MA
01752-1274
US

V. Phone/Fax

Practice location:
  • Phone: 508-229-3640
  • Fax: 508-229-7954
Mailing address:
  • Phone: 508-229-3640
  • Fax: 508-229-7954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number203288
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: