Provider Demographics
NPI:1467589358
Name:PRIVRATSKY, AUGUST BENJAMIN JR (PT, CP)
Entity Type:Individual
Prefix:
First Name:AUGUST
Middle Name:BENJAMIN
Last Name:PRIVRATSKY
Suffix:JR
Gender:M
Credentials:PT, CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:828 S HAYWARD ST
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-3823
Mailing Address - Country:US
Mailing Address - Phone:760-277-4034
Mailing Address - Fax:
Practice Address - Street 1:210 NEWPORT CENTER DR STE 3
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7505
Practice Address - Country:US
Practice Address - Phone:760-277-4034
Practice Address - Fax:949-719-2600
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
224P00000X
OK1797225100000X
UT350182-2401225100000X
TX1079887225100000X
CA29431225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT6147910001OtherMEDICARE PROSTHETIST, DME SUPPLIER
UT6147910001OtherMEDICARE PROSTHETIST, DME SUPPLIER