Provider Demographics
NPI:1548231160
Name:DISTLER, PETER M (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:M
Last Name:DISTLER
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 1:3 E 83RD ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-0459
Mailing Address - Country:US
Mailing Address - Phone:212-734-3444
Mailing Address - Fax:212-734-0370
Practice Address - Street 1:3 E 83RD ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-0459
Practice Address - Country:US
Practice Address - Phone:212-734-3444
Practice Address - Fax:212-734-0370
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-31
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY179238207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01476195Medicaid
NY01476195Medicaid
NY60H512Medicare ID - Type Unspecified