Provider Demographics
NPI:1790731677
Name:PETZOLDT, THOMAS D (OT)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:D
Last Name:PETZOLDT
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4010 MOORPARK AVE
Mailing Address - Street 2:STE 103
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95117-1842
Mailing Address - Country:US
Mailing Address - Phone:408-261-7660
Mailing Address - Fax:408-246-1574
Practice Address - Street 1:1062 SARATOGA AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95129-3402
Practice Address - Country:US
Practice Address - Phone:408-261-7660
Practice Address - Fax:408-246-1574
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT 5763225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ16196ZMedicare ID - Type UnspecifiedMEDICARE