Provider Demographics
NPI:1619977402
Name:DEMOS, PETER T (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:T
Last Name:DEMOS
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 1:125 LIBERTY ST
Mailing Address - Street 2:STE 403
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01103-1109
Mailing Address - Country:US
Mailing Address - Phone:413-739-6611
Mailing Address - Fax:
Practice Address - Street 1:125 LIBERTY ST
Practice Address - Street 2:STE 403
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01103-1109
Practice Address - Country:US
Practice Address - Phone:413-739-6611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-22
Last Update Date:2021-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA58416207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ06761OtherPROVIDER NUMBER
MA11753OtherHNE PROVIDER NUMBER
MA725076OtherTUFTS PROVIDER NUMBER
MA725076OtherTUFTS PROVIDER NUMBER
CT070000204Medicare ID - Type UnspecifiedPROVIDER NUMBER