Provider Demographics
NPI:1093775660
Name:ZDANKIEWICZ, PETER DONALD (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:DONALD
Last Name:ZDANKIEWICZ
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 1:10 MAIN ST S
Mailing Address - Street 2:
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488-2260
Mailing Address - Country:US
Mailing Address - Phone:888-338-8356
Mailing Address - Fax:888-366-1189
Practice Address - Street 1:10 MAIN ST S
Practice Address - Street 2:
Practice Address - City:SOUTHBURY
Practice Address - State:CT
Practice Address - Zip Code:06488-2260
Practice Address - Country:US
Practice Address - Phone:888-338-8356
Practice Address - Fax:888-366-1189
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-27
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT038476208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001384768Medicaid
CT001384768Medicaid
CTH17124Medicare UPIN