Provider Demographics
NPI:1518981976
Name:SQUIRE, PETER W (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:W
Last Name:SQUIRE
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 1:219 WEAVER AVENUE
Mailing Address - Street 2:
Mailing Address - City:EMPORIA
Mailing Address - State:VA
Mailing Address - Zip Code:23847
Mailing Address - Country:US
Mailing Address - Phone:434-634-4148
Mailing Address - Fax:434-634-6963
Practice Address - Street 1:219 WEAVER AVENUE
Practice Address - Street 2:
Practice Address - City:EMPORIA
Practice Address - State:VA
Practice Address - Zip Code:23847
Practice Address - Country:US
Practice Address - Phone:434-634-4148
Practice Address - Fax:434-634-6963
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101011670207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5609755Medicaid
VA5609755Medicaid