Provider Demographics
NPI:1649269432
Name:VANDOREN, PETER C (PT)
Entity type:Individual
Prefix:MR
First Name:PETER
Middle Name:C
Last Name:VANDOREN
Suffix:
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 1:9777 S YOSEMITE ST
Mailing Address - Street 2:STE 110
Mailing Address - City:LONE TREE
Mailing Address - State:CO
Mailing Address - Zip Code:80124-3191
Mailing Address - Country:US
Mailing Address - Phone:303-333-3493
Mailing Address - Fax:303-792-2405
Practice Address - Street 1:9777 S YOSEMITE ST
Practice Address - Street 2:STE 110
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124-3191
Practice Address - Country:US
Practice Address - Phone:303-333-3493
Practice Address - Fax:303-792-2405
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL-8652225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
803176Medicare PIN