Provider Demographics
NPI:1891996708
Name:PROCIUK, PETER JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:JOSEPH
Last Name:PROCIUK
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 1:322 N HIGH ST
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19380-2650
Mailing Address - Country:US
Mailing Address - Phone:610-701-5702
Mailing Address - Fax:610-701-4225
Practice Address - Street 1:322 N HIGH ST
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19380-2650
Practice Address - Country:US
Practice Address - Phone:610-701-5702
Practice Address - Fax:610-701-4225
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD039488L208D00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAF48916Medicare UPIN