Provider Demographics
NPI:1275690406
Name:BLAES, PETER VIGGO (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:VIGGO
Last Name:BLAES
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 1:208 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850
Mailing Address - Country:US
Mailing Address - Phone:301-309-8200
Mailing Address - Fax:301-309-9667
Practice Address - Street 1:208 MONROE ST
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850
Practice Address - Country:US
Practice Address - Phone:301-309-8200
Practice Address - Fax:301-309-9667
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00387002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC260048905OtherRAILROAD MEDICARE
DC584082T31Medicare PIN
DCE29963Medicare UPIN