Healthcare Provider Details

I. General information

NPI: 1518727387
Provider Name (Legal Business Name): STEVEN PERETIATKO MD A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2024
Last Update Date: 04/29/2024
Certification Date: 04/29/2024
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: 818-671-2225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: STEVEN PERETIATKO
Title or Position: OWNER
Credential: MD
Phone: 941-236-0461