Basic Information
| Provider Information | |||||||||
| NPI: | 1295922334 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DE JAGER | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | S.C. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1116 ARSENAL ST | ||||||||
| Address2: | SUITE 504 | ||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136012229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157822620 | ||||||||
| FaxNumber: | 3157884980 | ||||||||
| Practice Location | |||||||||
| Address1: | 830 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136014034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157854000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2007 | ||||||||
| LastUpdateDate: | 10/03/2007 | ||||||||
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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 | 207P00000X | 002948 | NY | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.