Provider Demographics
NPI:1598749285
Name:MASIAKOS, PETER THEODORE (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:THEODORE
Last Name:MASIAKOS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 9142
Mailing Address - Street 2:MASS GENERAL PHYSICIAN ORGANIZATION
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-726-8839
Mailing Address - Fax:617-726-2167
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:WRN 11 PEDIATRIC SURGERY
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2696
Practice Address - Country:US
Practice Address - Phone:617-726-8839
Practice Address - Fax:617-726-2167
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2012-11-30
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA216940208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ27581OtherBCBS MA
MA2065673Medicaid
MA469284OtherTUFTS HEALTH PLAN
I14066Medicare UPIN
MA2065673Medicaid