Provider Demographics
NPI:1194709246
Name:MIOTTO, PETER JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:JOHN
Last Name:MIOTTO
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 1:159 UNION ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:MARLBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01752-1274
Mailing Address - Country:US
Mailing Address - Phone:508-229-3640
Mailing Address - Fax:508-229-7954
Practice Address - Street 1:159 UNION ST
Practice Address - Street 2:SUITE 104
Practice Address - City:MARLBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01752-1274
Practice Address - Country:US
Practice Address - Phone:508-229-3640
Practice Address - Fax:508-229-7954
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA203288174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0130851Medicaid
MA203288OtherTUFTS HEALTH PLAN
MA61677OtherFALLON COMMUNITY HEALTH
MA808067OtherHARVARD PILGRIM HEALTH CA
MA203288OtherMA STATE LICENSE
MA61677OtherFALLON COMMUNITY HEALTH
MAF97983Medicare UPIN