Healthcare Provider Details

I. General information

NPI: 1104892488
Provider Name (Legal Business Name): PETER STEVEN MIDULLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 02/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 E 98TH ST 14TH FL
NEW YORK NY
10029-6574
US

IV. Provider business mailing address

5 E 98TH ST BOX 1259
NEW YORK NY
10029-6501
US

V. Phone/Fax

Practice location:
  • Phone: 212-241-1656
  • Fax: 212-534-2654
Mailing address:
  • Phone: 212-241-1608
  • Fax: 212-241-5975

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number188585
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: