Provider Demographics
NPI:1912139874
Name:ALLEN, PETER R (DPT)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:R
Last Name:ALLEN
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 1:5317A LAKESIDE AVE
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23228-6007
Mailing Address - Country:US
Mailing Address - Phone:804-303-4961
Mailing Address - Fax:
Practice Address - Street 1:5317A LAKESIDE AVE
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23228-6007
Practice Address - Country:US
Practice Address - Phone:804-303-4961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-11
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305205986225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1912139874Medicaid
VA9713373OtherAETNA
VA192944OtherBCBS (PHYSICAL THERAPY)
VAP00795443OtherRAILROAD MEDICARE
VA9713373OtherAETNA
VAP00795443OtherRAILROAD MEDICARE