Provider Demographics
NPI:1851012975
Name:PETERSON, KEVIN JOSEPH (DPT)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:JOSEPH
Last Name:PETERSON
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 1:9800 W COMMERCIAL BLVD
Mailing Address - Street 2:SUITE RP 104
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33351
Mailing Address - Country:US
Mailing Address - Phone:954-475-5500
Mailing Address - Fax:
Practice Address - Street 1:9800 W COMMERCIAL BLVD
Practice Address - Street 2:SUITE RP 104
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33351
Practice Address - Country:US
Practice Address - Phone:954-475-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-07
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT31552225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist