Provider Demographics
NPI:1790737377
Name:BLANK, PETER B (DO)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:B
Last Name:BLANK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 N FINLEY AVE
Mailing Address - Street 2:
Mailing Address - City:BASKING RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07920-1686
Mailing Address - Country:US
Mailing Address - Phone:908-340-4266
Mailing Address - Fax:908-340-4269
Practice Address - Street 1:150 N FINLEY AVE
Practice Address - Street 2:
Practice Address - City:BASKING RIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07920
Practice Address - Country:US
Practice Address - Phone:908-340-4266
Practice Address - Fax:908-340-4269
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT042957207X00000X
NJ25MB08046600207X00000X
NY223598207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJI26843Medicare UPIN
NJ102479Medicare PIN
NJ6587120001Medicare NSC
CTI26843Medicare UPIN