Provider Demographics
NPI:1316055742
Name:WIDDESS-WALSH, PETER (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:WIDDESS-WALSH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:18 E 41ST ST
Mailing Address - Street 2:STE 1206
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10017-6222
Mailing Address - Country:US
Mailing Address - Phone:212-725-8511
Mailing Address - Fax:212-726-7417
Practice Address - Street 1:200 S ORANGE AVE
Practice Address - Street 2:STE 101
Practice Address - City:LIVINGSTON
Practice Address - State:NJ
Practice Address - Zip Code:07039-5817
Practice Address - Country:US
Practice Address - Phone:973-322-7580
Practice Address - Fax:973-322-7505
Is Sole Proprietor?:No
Enumeration Date:2006-08-27
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA080825002084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
I64655Medicare UPIN
NJ104844P7SMedicare PIN