Provider Demographics
NPI:1497795900
Name:KRENICKY, PETER T (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:T
Last Name:KRENICKY
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 1:477 CONNECTICUT BLVD
Mailing Address - Street 2:STE 205
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108
Mailing Address - Country:US
Mailing Address - Phone:860-528-9645
Mailing Address - Fax:860-528-6366
Practice Address - Street 1:477 CONNECTICUT BLVD
Practice Address - Street 2:STE 205
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06108
Practice Address - Country:US
Practice Address - Phone:860-528-9645
Practice Address - Fax:860-528-6366
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT13523207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001135235Medicaid
010013523CTOtherBCBS OF CT
013523OtherCONNECTICARE
180000127Medicare ID - Type Unspecified
A30817Medicare UPIN