Provider Demographics
NPI:1972538767
Name:TREVOULEDES, PETER B (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:B
Last Name:TREVOULEDES
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 1:1201 GRAMPIAN BLVD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-1900
Mailing Address - Country:US
Mailing Address - Phone:570-326-8723
Mailing Address - Fax:
Practice Address - Street 1:10 SHADY LN STE 202
Practice Address - Street 2:
Practice Address - City:MUNCY
Practice Address - State:PA
Practice Address - Zip Code:17756-8807
Practice Address - Country:US
Practice Address - Phone:570-546-3633
Practice Address - Fax:570-546-3663
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD061452L208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016319440003Medicaid
PAG09891Medicare UPIN
PA0016319440003Medicaid