Provider Demographics
NPI:1154306108
Name:PETERS, GARY L (MD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:L
Last Name:PETERS
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 NEPONSET ST FL STREET2
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01606-2714
Mailing Address - Country:US
Mailing Address - Phone:508-368-5532
Mailing Address - Fax:508-368-3143
Practice Address - Street 1:123 SUMMER STREET
Practice Address - Street 2:SUITE 320
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608
Practice Address - Country:US
Practice Address - Phone:508-368-3140
Practice Address - Fax:508-368-3143
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA46267174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA6196101Medicaid
MAB74133Medicare UPIN
MAJ01105Medicare ID - Type Unspecified