Provider Demographics
NPI:1154416782
Name:GATES, PETER J (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:J
Last Name:GATES
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 1:157 MONTAUK AVENUE
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320
Mailing Address - Country:US
Mailing Address - Phone:860-437-0333
Mailing Address - Fax:860-439-1330
Practice Address - Street 1:157 MONTAUK AVENUE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320
Practice Address - Country:US
Practice Address - Phone:860-437-0333
Practice Address - Fax:860-439-1330
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT016287207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTB84468Medicare UPIN
080001580Medicare ID - Type Unspecified