Provider Demographics
NPI:1588841068
Name:BERTOLOZZI, PETER PAUL JR (DO)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:PAUL
Last Name:BERTOLOZZI
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:365 MONTAUK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-4700
Mailing Address - Country:US
Mailing Address - Phone:860-442-0711
Mailing Address - Fax:
Practice Address - Street 1:255 MICHELLE LN
Practice Address - Street 2:APT 306
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-4239
Practice Address - Country:US
Practice Address - Phone:617-448-1589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-27
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT49914207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5315031607OtherCONTROLLED SUBSTANCE LIS
MI5101017291OtherEDUCATION LISCENCE