Basic Information
| Provider Information | |||||||||
| NPI: | 1154407997 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | JUDGE | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 45 RESEARCH WAY SUITE 204B | ||||||||
| Address2: | UNIVERSITY ASSOCIATES OBGYN | ||||||||
| City: | EAST SETAUKET | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6316158272 | ||||||||
| FaxNumber: | 6313507200 | ||||||||
| Practice Location | |||||||||
| Address1: | 320 MONTAUK HIGHWAY | ||||||||
| Address2: | SOUTH BAY OB GYN PC | ||||||||
| City: | WEST ISLIP | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117954401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6315872500 | ||||||||
| FaxNumber: | 6315870292 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 06/16/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 1672631 | NY | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | CP194 | 01 | NY | OXFORD | OTHER | 124813 | 05 | NY | MEDICAID | 0200238 | 01 | NY | GHI | OTHER |