Provider Demographics
NPI:1164451555
Name:PETERS, RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:PETERS
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 1:55 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-4274
Mailing Address - Country:US
Mailing Address - Phone:516-764-2115
Mailing Address - Fax:516-764-1323
Practice Address - Street 1:55 MAPLE AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-4274
Practice Address - Country:US
Practice Address - Phone:516-764-2115
Practice Address - Fax:516-764-1323
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2017-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME78580207L00000X
NC200000933207L00000X
NY156229-1207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1183224Medicaid
NYE20360Medicare UPIN
NY1183224Medicaid