Basic Information
| Provider Information | |||||||||
| NPI: | 1093750028 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OTTAVIO | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | |||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 COMMACK RD | ||||||||
| Address2: | |||||||||
| City: | COMMACK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117255020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6316752125 | ||||||||
| FaxNumber: | 6316752628 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 ROUTE 112 STE B | ||||||||
| Address2: | |||||||||
| City: | PORT JEFFERSON STATION | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117768055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6319787633 | ||||||||
| FaxNumber: | 6316214115 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 10/22/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 232660 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0200X | 232660 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RS0012X | 232660 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | 207RP1001X | 232660 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 232660 | 01 | NY | LICENSE NUMBER | OTHER |