Provider Demographics
NPI:1508838962
Name:PETERSON, EUGENE J (PT)
Entity Type:Individual
Prefix:
First Name:EUGENE
Middle Name:J
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21501 BROOKHURST ST
Mailing Address - Street 2:STE. E.
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92646-8080
Mailing Address - Country:US
Mailing Address - Phone:714-963-7712
Mailing Address - Fax:714-965-0682
Practice Address - Street 1:21501 BROOKHURST ST
Practice Address - Street 2:STE. E.
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92646-8080
Practice Address - Country:US
Practice Address - Phone:714-963-7712
Practice Address - Fax:714-965-0682
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT29622225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT29662Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID#