Provider Demographics
NPI:1619904232
Name:PETERS, JEFFREY HAROLD
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:HAROLD
Last Name:PETERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 ELMWOOD AVE
Mailing Address - Street 2:BOX SURG
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-8410
Mailing Address - Country:US
Mailing Address - Phone:585-275-2725
Mailing Address - Fax:585-275-8513
Practice Address - Street 1:601 ELMWOOD AVE
Practice Address - Street 2:BOX SURG
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14642-8410
Practice Address - Country:US
Practice Address - Phone:585-275-2725
Practice Address - Fax:585-275-8513
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY232478208G00000X, 2086S0102X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02565162Medicaid
NYJ400025568Medicare PIN
D74396Medicare UPIN