Healthcare Provider Details

I. General information

NPI: 1053871491
Provider Name (Legal Business Name): STEVEN PERETIATKO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2019
Last Update Date: 11/15/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1303 MABLE AVE
MODESTO CA
95355-1119
US

IV. Provider business mailing address

PO BOX 872
AGOURA HILLS CA
91376-0872
US

V. Phone/Fax

Practice location:
  • Phone: 209-857-3400
  • Fax: 818-671-2225
Mailing address:
  • Phone: 818-518-7226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberA190660
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: