Provider Demographics
NPI:1396715231
Name:ANDERSON, PETER LLOYD (MD)
Entity type:Individual
Prefix:MR
First Name:PETER
Middle Name:LLOYD
Last Name:ANDERSON
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 1:1 OLD PARK LANE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:NEW MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06776
Mailing Address - Country:US
Mailing Address - Phone:860-355-3728
Mailing Address - Fax:860-355-4253
Practice Address - Street 1:1 OLD PARK LANE
Practice Address - Street 2:SUITE 2
Practice Address - City:NEW MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06776
Practice Address - Country:US
Practice Address - Phone:860-355-3728
Practice Address - Fax:860-355-4253
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT025352174400000X, 207Q00000X
CT000613174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001253525Medicaid
CT001253525Medicaid
C01692Medicare PIN
B38456Medicare UPIN