Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207K00000X | Allergist & Immunologist | 35073238 | OH |
N | 207R00000X | Internist | 35073238 | OH |
N | 111NI0900X | Internist | 35073238 | OH |
N | 207RA0201X | Internist - Allergy & Immunology | 35073238 | OH |
N | 208000000X | Pediatrician | 35073238 | OH |
Y | 2080P0201X | Pediatric Allergist | 35073238 | OH |
NPI | 1730173758 |
---|---|
Provider Name | Peter John Mustillo |
First Address | Columbus, OH 43205-2664 |
Second Address | Columbus, OH 43205-2664 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/09/2005 |
Last Update Date | 14/11/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2154403 | (05) | OH |
3004870000 | (05) | WV |
64047764 | (05) | KY |