Provider Demographics
NPI:1114554581
Name:BLOSSER, PETER (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:BLOSSER
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 1:626 BERKMAR CIR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22901-1464
Mailing Address - Country:US
Mailing Address - Phone:434-295-3227
Mailing Address - Fax:434-295-9527
Practice Address - Street 1:626 BERKMAR CIR
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22901-1464
Practice Address - Country:US
Practice Address - Phone:434-295-3227
Practice Address - Fax:434-295-9527
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-25
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0101281578207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program