Provider Demographics
NPI:1376504720
Name:MARIS, PETER J G (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:J G
Last Name:MARIS
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 1:230 HILTON AVE
Mailing Address - Street 2:STE 118
Mailing Address - City:HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11550
Mailing Address - Country:US
Mailing Address - Phone:516-481-1570
Mailing Address - Fax:516-481-1786
Practice Address - Street 1:230 HILTON AVE
Practice Address - Street 2:STE 118
Practice Address - City:HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11550
Practice Address - Country:US
Practice Address - Phone:516-481-1570
Practice Address - Fax:516-481-1786
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-28
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY085829207W00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00132114.Medicaid
B80479Medicare UPIN
431191Medicare ID - Type Unspecified
NY00132114.Medicaid