Provider Demographics
NPI:1982082699
Name:MUGNOLO, PETER T (LMT)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:T
Last Name:MUGNOLO
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 HONEOYE FALLS FIVE PT RD
Mailing Address - Street 2:
Mailing Address - City:RUSH
Mailing Address - State:NY
Mailing Address - Zip Code:14543-9415
Mailing Address - Country:US
Mailing Address - Phone:585-503-5106
Mailing Address - Fax:
Practice Address - Street 1:16 GOODMAN ST N
Practice Address - Street 2:SUITE 214
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14607-1554
Practice Address - Country:US
Practice Address - Phone:585-503-5106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-13
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010109174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist