Provider Demographics
NPI:1821102161
Name:PETERS, NICHOLAS S (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:S
Last Name:PETERS
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 1:149 PARIS RD
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413-2428
Mailing Address - Country:US
Mailing Address - Phone:315-794-5811
Mailing Address - Fax:
Practice Address - Street 1:267 HILL ROAD
Practice Address - Street 2:SUITE 200
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13441
Practice Address - Country:US
Practice Address - Phone:315-338-7540
Practice Address - Fax:315-338-7538
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY153507207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY153507Medicaid
J70061Medicare ID - Type Unspecified
NY153507Medicaid