Provider Demographics
NPI:1710935564
Name:GIACOMAZZI, PETER (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:GIACOMAZZI
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 1:503 WOLCOTT RD
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:WOLCOTT
Mailing Address - State:CT
Mailing Address - Zip Code:06716
Mailing Address - Country:US
Mailing Address - Phone:203-879-8003
Mailing Address - Fax:203-879-8010
Practice Address - Street 1:503 WOLCOTT RD
Practice Address - Street 2:
Practice Address - City:WOLCOTT
Practice Address - State:CT
Practice Address - Zip Code:06716-2613
Practice Address - Country:US
Practice Address - Phone:203-879-7925
Practice Address - Fax:203-879-7935
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT041953207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001419531Medicaid
CT001419531Medicaid
CT110009063Medicare ID - Type Unspecified