Provider Demographics
NPI:1063400349
Name:DEWIRE, PETER (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:DEWIRE
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 1:54 MILLER ST
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-4725
Mailing Address - Country:US
Mailing Address - Phone:617-376-2017
Mailing Address - Fax:617-376-2043
Practice Address - Street 1:54 MILLER ST
Practice Address - Street 2:4TH FLOOR
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-4725
Practice Address - Country:US
Practice Address - Phone:617-376-2017
Practice Address - Fax:617-376-2043
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA58417207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3070174Medicaid
058417OtherTUFTS
E67264Medicare UPIN
J10446Medicare PIN