Provider Demographics
NPI:1356480495
Name:DYNER, PETER Q (DPM)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:Q
Last Name:DYNER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:273 HAMPTON RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11968-5027
Mailing Address - Country:US
Mailing Address - Phone:631-283-1123
Mailing Address - Fax:631-283-2766
Practice Address - Street 1:273 HAMPTON RD
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968-5027
Practice Address - Country:US
Practice Address - Phone:631-283-1123
Practice Address - Fax:631-283-2766
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN003833-1213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY10823OtherVYTRA
NY0098386OtherGHI
NYCS614OtherOXFORD
NYCS614OtherOXFORD
NYP40091Medicare PIN