Provider Demographics
NPI:1417043639
Name:WITHAM, PETER H (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:H
Last Name:WITHAM
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 1:50 UNION STREET
Mailing Address - Street 2:
Mailing Address - City:ELLSWORTH
Mailing Address - State:ME
Mailing Address - Zip Code:04605
Mailing Address - Country:US
Mailing Address - Phone:207-664-7780
Mailing Address - Fax:207-664-7721
Practice Address - Street 1:16 COMMUNITY LN
Practice Address - Street 2:
Practice Address - City:SOUTHWEST HARBOR
Practice Address - State:ME
Practice Address - Zip Code:04679-4273
Practice Address - Country:US
Practice Address - Phone:207-244-5630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD19832207R00000X
VT0420010126207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTOVN2345Medicaid
E87692Medicare UPIN
VTOVN2345Medicaid