Provider Demographics
NPI:1104892488
Name:MIDULLA, PETER STEVEN (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:STEVEN
Last Name:MIDULLA
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 1:5 E 98TH ST
Mailing Address - Street 2:BOX 1259
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-6501
Mailing Address - Country:US
Mailing Address - Phone:212-241-1608
Mailing Address - Fax:212-241-5975
Practice Address - Street 1:5 E 98TH ST
Practice Address - Street 2:14TH FL
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6574
Practice Address - Country:US
Practice Address - Phone:212-241-1656
Practice Address - Fax:212-534-2654
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-27
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY1885852086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01936185Medicaid
NY01936185Medicaid
NY81L213Medicare ID - Type Unspecified