Provider Demographics
NPI:1649544081
Name:WISTREICH, PETER MICHAEL
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:MICHAEL
Last Name:WISTREICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:267 S BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:NYACK
Mailing Address - State:NY
Mailing Address - Zip Code:10960-4114
Mailing Address - Country:US
Mailing Address - Phone:914-217-6450
Mailing Address - Fax:845-358-3686
Practice Address - Street 1:267 S BOULEVARD
Practice Address - Street 2:
Practice Address - City:NYACK
Practice Address - State:NY
Practice Address - Zip Code:10960-4114
Practice Address - Country:US
Practice Address - Phone:914-217-6450
Practice Address - Fax:845-358-3686
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-02
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY150164207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY150164OtherSTATE LICENSURE