Provider Demographics
NPI:1003083775
Name:DE SANCTIS, PETER NICHOLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:NICHOLAS
Last Name:DE SANCTIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:PETER
Other - Middle Name:NICHOLAS
Other - Last Name:DE SANCTIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1957
Mailing Address - Street 2:
Mailing Address - City:SHELTER ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:11964-1957
Mailing Address - Country:US
Mailing Address - Phone:631-749-4154
Mailing Address - Fax:631-749-3663
Practice Address - Street 1:115 SOUTH FERRY ROAD
Practice Address - Street 2:
Practice Address - City:SHELTER ISLAND
Practice Address - State:NY
Practice Address - Zip Code:11964-1957
Practice Address - Country:US
Practice Address - Phone:631-749-4154
Practice Address - Fax:631-749-3663
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-13
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY91459208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY91459Medicare PIN