Provider Demographics
NPI:1053463547
Name:VELLIS, PETER ALEXANDER (DO)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:ALEXANDER
Last Name:VELLIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12222-1000
Mailing Address - Country:US
Mailing Address - Phone:518-442-5461
Mailing Address - Fax:518-442-5444
Practice Address - Street 1:1400 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12222-1000
Practice Address - Country:US
Practice Address - Phone:518-442-5461
Practice Address - Fax:518-442-5444
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY173769207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYE47358Medicare UPIN