Provider Demographics
NPI:1053358143
Name:RECUPERO, PETER J (DO)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:J
Last Name:RECUPERO
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 1:2000 HEALTH PARK DR FL HP2
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4692
Mailing Address - Country:US
Mailing Address - Phone:615-373-7600
Mailing Address - Fax:
Practice Address - Street 1:3700 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-7017
Practice Address - Country:US
Practice Address - Phone:540-951-1111
Practice Address - Fax:540-953-5158
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS9238174400000X
VA0102202542208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1053358143Medicaid
VAP00822724OtherRR MEDICARE
VA1053358143Medicaid
FLI00573Medicare UPIN
FL48631ZMedicare ID - Type Unspecified