Provider Demographics
NPI:1376526814
Name:BLUME, PETER A (DPMFACFAS)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:A
Last Name:BLUME
Suffix:
Gender:M
Credentials:DPMFACFAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 BLAKE ST
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06515-1287
Mailing Address - Country:US
Mailing Address - Phone:203-397-0624
Mailing Address - Fax:203-397-0372
Practice Address - Street 1:508 BLAKE ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06515-1287
Practice Address - Country:US
Practice Address - Phone:203-397-0624
Practice Address - Fax:203-397-0372
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000581213E00000X, 213EP1101X, 213ES0131X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004121414Medicaid
U42618Medicare UPIN
CT004121414Medicaid
CT0639830001Medicare NSC