Provider Demographics
NPI:1518115369
Name:PETRE, BRENT A (DPT)
Entity Type:Individual
Prefix:MR
First Name:BRENT
Middle Name:A
Last Name:PETRE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4910 DIRECTORS PL
Mailing Address - Street 2:SUITE 370
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-3811
Mailing Address - Country:US
Mailing Address - Phone:858-554-0522
Mailing Address - Fax:858-554-0536
Practice Address - Street 1:4910 DIRECTORS PL
Practice Address - Street 2:SUITE 370
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-3811
Practice Address - Country:US
Practice Address - Phone:858-554-0522
Practice Address - Fax:858-554-0536
Is Sole Proprietor?:No
Enumeration Date:2008-09-05
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT34764225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAZ971ZOtherMEDICARE PTAN