Provider Demographics
NPI:1730188020
Name:EWERT, PETER JEFFREY (PHD)
Entity type:Individual
Prefix:MR
First Name:PETER
Middle Name:JEFFREY
Last Name:EWERT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6853 FAIRVIEW RD
Mailing Address - Street 2:STE B
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3363
Mailing Address - Country:US
Mailing Address - Phone:704-366-9930
Mailing Address - Fax:704-366-9931
Practice Address - Street 1:6853 FAIRVIEW RD
Practice Address - Street 2:STE B
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-3363
Practice Address - Country:US
Practice Address - Phone:704-366-9930
Practice Address - Fax:704-366-9931
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1548103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
2811921BMedicare ID - Type Unspecified
C83191Medicare UPIN