Provider Demographics
NPI:1558927954
Name:PETERS, SHANICE (MD)
Entity Type:Individual
Prefix:
First Name:SHANICE
Middle Name:
Last Name:PETERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 NORTHFIELD AVENUE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10303
Mailing Address - Country:US
Mailing Address - Phone:868-485-4508
Mailing Address - Fax:
Practice Address - Street 1:355 GRAND STREET
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07302
Practice Address - Country:US
Practice Address - Phone:201-915-2431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-13
Last Update Date:2023-12-12
Deactivation Date:2020-01-17
Deactivation Code:
Reactivation Date:2020-06-27
Provider Licenses
StateLicense IDTaxonomies
390200000X
SC87592207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program