Provider Demographics
NPI:1053343343
Name:PETER, JOSEPH PHILLIP (MD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:PHILLIP
Last Name:PETER
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-254-5920
Mailing Address - Fax:239-254-5921
Practice Address - Street 1:332 MEDCREST DRIVE
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536
Practice Address - Country:US
Practice Address - Phone:850-683-5100
Practice Address - Fax:850-683-5102
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME74916208D00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL255307400Medicaid
G45048Medicare UPIN