Provider Demographics
NPI:1316925407
Name:SPAGNOLI, PETER (PT)
Entity type:Individual
Prefix:MR
First Name:PETER
Middle Name:
Last Name:SPAGNOLI
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 CLIFF DR
Mailing Address - Street 2:
Mailing Address - City:SAG HARBOR
Mailing Address - State:NY
Mailing Address - Zip Code:11963-1804
Mailing Address - Country:US
Mailing Address - Phone:631-467-4235
Mailing Address - Fax:631-467-2655
Practice Address - Street 1:141 MARK TREE RD
Practice Address - Street 2:
Practice Address - City:CENTEREACH
Practice Address - State:NY
Practice Address - Zip Code:11720-2221
Practice Address - Country:US
Practice Address - Phone:631-467-4235
Practice Address - Fax:631-467-2655
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008621-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ54612Medicare PIN