Provider Demographics
NPI:1457313371
Name:SHRIVER, PETER A (DO)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:A
Last Name:SHRIVER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:400 SAYBROOK ROAD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-4773
Mailing Address - Country:US
Mailing Address - Phone:860-347-7466
Mailing Address - Fax:860-347-2619
Practice Address - Street 1:400 SAYBROOK ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-4773
Practice Address - Country:US
Practice Address - Phone:860-347-7466
Practice Address - Fax:860-347-2619
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT044842207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D05887Medicare UPIN
804872Medicare ID - Type Unspecified