Provider Demographics
NPI:1255396743
Name:BOUDO, PETER G JR (PT)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:G
Last Name:BOUDO
Suffix:JR
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:PO BOX 8
Mailing Address - Street 2:
Mailing Address - City:EAST HAMPTON
Mailing Address - State:CT
Mailing Address - Zip Code:06424-0008
Mailing Address - Country:US
Mailing Address - Phone:860-267-8500
Mailing Address - Fax:860-986-7459
Practice Address - Street 1:14 JONES HOLLOW RD STE 7
Practice Address - Street 2:
Practice Address - City:MARLBOROUGH
Practice Address - State:CT
Practice Address - Zip Code:06447-1448
Practice Address - Country:US
Practice Address - Phone:860-295-8188
Practice Address - Fax:860-986-7459
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005971225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist