Provider Demographics
NPI:1790783975
Name:HOTVEDT, PETER S (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:S
Last Name:HOTVEDT
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 1:2211 GENESEE ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-5930
Mailing Address - Country:US
Mailing Address - Phone:315-733-7598
Mailing Address - Fax:315-733-2102
Practice Address - Street 1:2211 GENESEE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-5930
Practice Address - Country:US
Practice Address - Phone:315-733-7598
Practice Address - Fax:315-733-2102
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY202660207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01648264Medicaid
NY39498DMedicare ID - Type Unspecified
NY01648264Medicaid