Provider Demographics
NPI:1881996163
Name:PINEDA, JOHN CARL PERALTA (DPT)
Entity type:Individual
Prefix:MR
First Name:JOHN CARL
Middle Name:PERALTA
Last Name:PINEDA
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 1:77 DOTY RD
Mailing Address - Street 2:
Mailing Address - City:HASKELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07420
Mailing Address - Country:US
Mailing Address - Phone:917-618-9881
Mailing Address - Fax:
Practice Address - Street 1:77 DOTY RD
Practice Address - Street 2:
Practice Address - City:HASKELL
Practice Address - State:NJ
Practice Address - Zip Code:07420-3713
Practice Address - Country:US
Practice Address - Phone:917-618-9881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-19
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029628225100000X
NJ40QA01347600225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ40QA01347600OtherPT LICENSE
NJ40QA01347600OtherPT LICENSE