MEDICARE: DANIEL PETERSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT31824	FL

General Provider Information

NPI Number	:	1295211878
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIEL PETERSON

Provider Business Mailing Address
First Line	:	21756 STATE ROAD 54 STE 102
Second Line	:
City	:	LUTZ
State	:	FL
Zip	:	33549-2905
Country	:	US
Telephone Number	:	440-475-5540
Fax Number	:	844-927-4950

Provider Business Practice Location Address
First Line	:	2600 DR MLK JR STREET N
Second Line	:	STE 200B
City	:	ST PETERSBURG
State	:	FL
Zip	:	33704-2744
Country	:	US
Telephone Number	:	727-202-4625
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/17/2018
Last Update Date	:	12/10/2021

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