Provider Demographics
NPI:1568488187
Name:WELLER, PETER T (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:T
Last Name:WELLER
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:PO BOX 547
Mailing Address - Street 2:ATT: CVMC FINANCE DEPT
Mailing Address - City:BARRE
Mailing Address - State:VT
Mailing Address - Zip Code:05641-0547
Mailing Address - Country:US
Mailing Address - Phone:802-371-4263
Mailing Address - Fax:802-371-4481
Practice Address - Street 1:130 FISHER RD
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:VT
Practice Address - Zip Code:05602-9516
Practice Address - Country:US
Practice Address - Phone:802-371-4263
Practice Address - Fax:802-371-4481
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0008740207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTOVN0684Medicaid
VN0684Medicare ID - Type Unspecified
VTOVN0684Medicaid