Provider Demographics
NPI:1740304211
Name:VACCARO, PETER (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:VACCARO
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:BANK OF AMERICA FILE NUMBER 54701
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-4701
Mailing Address - Country:US
Mailing Address - Phone:909-651-4300
Mailing Address - Fax:
Practice Address - Street 1:2510 MONTAUK HIGHWAY
Practice Address - Street 2:
Practice Address - City:BRIDGEHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11932
Practice Address - Country:US
Practice Address - Phone:631-386-3600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY150913208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY112840592OtherTAX ID NUMBER