1265558498 NPI number — THOMAS M PELUSO PA

Table of content: THOMAS M PELUSO PA (NPI 1265558498)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265558498 NPI number — THOMAS M PELUSO PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PELUSO
Provider First Name:
THOMAS
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265558498
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
150 TEJAS PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NIPOMO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93444-9123
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-929-3211
Provider Business Mailing Address Fax Number:
805-929-6440

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7512 MORRO RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATASCADERO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93422-4404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-792-1400
Provider Business Practice Location Address Fax Number:
805-792-1485
Provider Enumeration Date:
03/21/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA11945 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: W1508C . This is a "MEDICARE GROUP PLAN-ATASCADERO" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: BC021Z . This is a "PTAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: W1508A . This is a "MEDICARE GROUP PLAN-TEMPLETON" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1275550295 . This is a "NPI-CHCCC TEMPLETON" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1073533089 . This is a "NPI - ATASCADERO" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".