Provider Demographics
NPI:1720294200
Name:SANDWELL, PETER GERARD (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:GERARD
Last Name:SANDWELL
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 1:23 ORCUTT CT
Mailing Address - Street 2:
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-1926
Mailing Address - Country:US
Mailing Address - Phone:860-874-4323
Mailing Address - Fax:203-745-3568
Practice Address - Street 1:1572 DURHAM RD
Practice Address - Street 2:
Practice Address - City:PENNDEL
Practice Address - State:PA
Practice Address - Zip Code:19047
Practice Address - Country:US
Practice Address - Phone:215-752-1541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD111692084P0804X
NY2426472084P0804X
PAMD019895E2084P0804X
CT0390732084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT260003720Medicare ID - Type Unspecified
CTH39150Medicare UPIN