Provider Demographics
NPI:1205993409
Name:MOLEY, PETER J (MD)
Entity type:Individual
Prefix:MR
First Name:PETER
Middle Name:J
Last Name:MOLEY
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 1:1 BLACHLEY ROAD
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902
Mailing Address - Country:US
Mailing Address - Phone:203-705-2349
Mailing Address - Fax:646-797-8866
Practice Address - Street 1:1 BLACHLEY ROAD
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902
Practice Address - Country:US
Practice Address - Phone:203-705-2120
Practice Address - Fax:646-797-8866
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT040335208100000X, 174400000X
NY221024174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0801J1Medicaid
NYP2711804OtherOXFORD
CTP2711804OtherOXFORD
NYH69098Medicare UPIN
CTH69098Medicare UPIN
NY0801J1Medicaid