Provider Demographics
NPI:1053409458
Name:GRUBER, PETER J (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:J
Last Name:GRUBER
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:668 MILTON RD APT A
Mailing Address - Street 2:
Mailing Address - City:RYE
Mailing Address - State:NY
Mailing Address - Zip Code:10580-3227
Mailing Address - Country:US
Mailing Address - Phone:610-888-9455
Mailing Address - Fax:
Practice Address - Street 1:330 CEDAR ST FL BB2
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510
Practice Address - Country:US
Practice Address - Phone:610-888-9455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT57299208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1053409458Medicaid
UTU000074454Medicare PIN