Healthcare Provider Details

I. General information

NPI: 1609996040
Provider Name (Legal Business Name): PETER MARTINDALE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 12/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 PROSPECT AVE
HACKENSACK NJ
07601-2510
US

IV. Provider business mailing address

235 PROSPECT AVE
HACKENSACK NJ
07601-2510
US

V. Phone/Fax

Practice location:
  • Phone: 201-342-8933
  • Fax: 201-342-2843
Mailing address:
  • Phone: 201-342-8933
  • Fax: 201-342-2843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number25MA03585300
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: