Provider Demographics
NPI:1407899800
Name:WILSON, PETER H (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:H
Last Name:WILSON
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 1:250 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-7539
Mailing Address - Country:US
Mailing Address - Phone:603-227-7000
Mailing Address - Fax:
Practice Address - Street 1:246 PLEASANT ST
Practice Address - Street 2:MEMORIAL BUILDING, SUITE 205
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-2548
Practice Address - Country:US
Practice Address - Phone:603-224-0584
Practice Address - Fax:603-225-5769
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT026080174400000X
NH15052208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30209947Medicaid
CT001260801Medicaid
CT020000763Medicare ID - Type Unspecified
NH30209947Medicaid