Provider Demographics
NPI:1720178593
Name:WYNNE, PETER J (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:J
Last Name:WYNNE
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 1:10 LANIDEX PLZ W
Mailing Address - Street 2:SUITE 125
Mailing Address - City:PARSIPPANY
Mailing Address - State:NJ
Mailing Address - Zip Code:07054-2715
Mailing Address - Country:US
Mailing Address - Phone:973-267-1274
Mailing Address - Fax:973-267-2912
Practice Address - Street 1:100 MADISON AVE
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07960-6136
Practice Address - Country:US
Practice Address - Phone:973-267-1274
Practice Address - Fax:973-267-2912
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA077458002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6602401Medicaid
NJG08503Medicare UPIN
NJ084816Medicare ID - Type Unspecified