Provider Demographics
NPI:1225108483
Name:DE JONG, PETER (PT, CFMT, MTC)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:DE JONG
Suffix:
Gender:M
Credentials:PT, CFMT, MTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 E PIKES PEAK AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-3611
Mailing Address - Country:US
Mailing Address - Phone:719-473-2958
Mailing Address - Fax:719-473-1004
Practice Address - Street 1:502 E PIKES PEAK AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-3611
Practice Address - Country:US
Practice Address - Phone:719-473-2958
Practice Address - Fax:719-473-1004
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6090225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO538918Medicare ID - Type Unspecified