Provider Demographics
NPI:1538108675
Name:PEKAREK, BRIAN THOMAS (DPM)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:THOMAS
Last Name:PEKAREK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 PENNY LN STE 1
Mailing Address - Street 2:
Mailing Address - City:WATSONVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95076-6055
Mailing Address - Country:US
Mailing Address - Phone:831-728-8844
Mailing Address - Fax:831-763-1001
Practice Address - Street 1:47 PENNY LN STE 1
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-6055
Practice Address - Country:US
Practice Address - Phone:831-728-8844
Practice Address - Fax:831-763-1001
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL278213E00000X, 213ES0103X
OH36 003501213ES0103X
CAE5177213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1563848OtherMEDICAID GROUP
AL051556220Medicaid
OHCH5179OtherRR MEDICARE GROUP
OHCH5179OtherRR MEDICARE GROUP
OH9312431Medicare PIN
ALV05525Medicare UPIN
AL051556220Medicare ID - Type Unspecified