Provider Demographics
NPI:1043393580
Name:ZULLO, PETER JOHN (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:JOHN
Last Name:ZULLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:856 J CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7547 MEDICAL DRIVE
Practice Address - Street 2:SUITE 2200
Practice Address - City:GLOUCESTER
Practice Address - State:VA
Practice Address - Zip Code:23061
Practice Address - Country:US
Practice Address - Phone:804-693-2720
Practice Address - Fax:804-694-0597
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101041375207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1043393580Medicaid
VA1043393580Medicaid
VA015367R53Medicare PIN
VAP00397235Medicare PIN