Provider Demographics
NPI:1134192602
Name:AULT, PETER N (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:N
Last Name:AULT
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 1:815 W POYTHRESS ST
Mailing Address - Street 2:
Mailing Address - City:HOPEWELL
Mailing Address - State:VA
Mailing Address - Zip Code:23860-2532
Mailing Address - Country:US
Mailing Address - Phone:804-458-8557
Mailing Address - Fax:804-541-7113
Practice Address - Street 1:815 W POYTHRESS ST
Practice Address - Street 2:
Practice Address - City:HOPEWELL
Practice Address - State:VA
Practice Address - Zip Code:23860-2532
Practice Address - Country:US
Practice Address - Phone:804-458-8557
Practice Address - Fax:804-541-7113
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101029899207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1134192602Medicaid
VA226152OtherANTHEM
VA005829062Medicaid
VAB08454Medicare UPIN
VA1134192602Medicaid
P00775596Medicare PIN
VA110007484Medicare PIN
VAVAA101186Medicare PIN
VA110198305Medicare PIN