Provider Demographics
NPI:1871770073
Name:PODBIELSKI, PETER (PT DPT)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:PODBIELSKI
Suffix:
Gender:M
Credentials:PT DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4110 N 108 AVE
Mailing Address - Street 2:#103
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85037
Mailing Address - Country:US
Mailing Address - Phone:623-877-9915
Mailing Address - Fax:623-877-1550
Practice Address - Street 1:4110 N 108 AVE
Practice Address - Street 2:#103
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037
Practice Address - Country:US
Practice Address - Phone:623-877-9915
Practice Address - Fax:623-877-1550
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-30
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7846225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ304771Medicaid
AZLICENSEOtherLICENSE
AZ304771Medicaid