1518727387 NPI number — STEVEN PERETIATKO MD A MEDICAL CORPORATION

Table of content: DR. SUZANNE BARNDT TRAVERS M.D. (NPI 1255696886)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518727387 NPI number — STEVEN PERETIATKO MD A MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STEVEN PERETIATKO MD A MEDICAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1518727387
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/29/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 872
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AGOURA HILLS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91376-0872
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-518-7226
Provider Business Mailing Address Fax Number:
818-671-2225

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1303 MABLE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MODESTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95355-1119
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-857-3400
Provider Business Practice Location Address Fax Number:
818-671-2225
Provider Enumeration Date:
03/20/2024

Additional Information

Authorized Official

Authorized Official Last Name:
PERETIATKO
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
941-236-0461

Provider Taxonomy Codes

  • Taxonomy code: 208100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: A190660 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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