Provider Demographics
NPI:1548243314
Name:BRYNILDSEN, PETER JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:JOHN
Last Name:BRYNILDSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:75 BLOOMFIELD AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:DENVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07834-2734
Mailing Address - Country:US
Mailing Address - Phone:973-625-3636
Mailing Address - Fax:973-625-3394
Practice Address - Street 1:75 BLOOMFIELD AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:DENVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07834-2734
Practice Address - Country:US
Practice Address - Phone:973-625-3636
Practice Address - Fax:973-625-3394
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA04177100208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJC59104Medicare UPIN
NJBR125445Medicare ID - Type Unspecified