Provider Demographics
NPI:1699705467
Name:WALDMAN, PETER J (DO)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:J
Last Name:WALDMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 PLEASANT ST
Mailing Address - Street 2:STE 204
Mailing Address - City:NEW LONDON
Mailing Address - State:NH
Mailing Address - Zip Code:03257-5881
Mailing Address - Country:US
Mailing Address - Phone:802-658-5756
Mailing Address - Fax:
Practice Address - Street 1:110 KIMBALL AVE STE 115
Practice Address - Street 2:
Practice Address - City:S BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-6841
Practice Address - Country:US
Practice Address - Phone:802-658-5756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT03200005272083P0500X
VT363A00000X207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ588692Medicare ID - Type Unspecified
NJD19497Medicare UPIN