Healthcare Provider Details

I. General information

NPI: 1699705467
Provider Name (Legal Business Name): PETER J WALDMAN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 01/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 KIMBALL AVE STE 115
S BURLINGTON VT
05403-6841
US

IV. Provider business mailing address

74 PLEASANT ST STE 204
NEW LONDON NH
03257-5881
US

V. Phone/Fax

Practice location:
  • Phone: 802-658-5756
  • Fax:
Mailing address:
  • Phone: 802-658-5756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number363A00000X
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License Number0320000527
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: