Provider Demographics
NPI:1619001468
Name:FISK, PETER E (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:E
Last Name:FISK
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 1:6 WELLNESS WAY STE 201
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2156
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:6 WELLNESS WAY STE G03
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-2156
Practice Address - Country:US
Practice Address - Phone:518-785-5884
Practice Address - Fax:518-783-6890
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036118047208600000X
VT060-0003317390200000X
NY249922208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP00857183OtherRR MEDICARE
NY03028439Medicaid
NYP00857183OtherRR MEDICARE
NYJ400016622Medicare PIN