Basic Information
| Provider Information | |||||||||
| NPI: | 1053345074 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENTLEY | ||||||||
| FirstName: | PETER | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3233 PALM AVE | ||||||||
| Address2: | |||||||||
| City: | HIALEAH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330125427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3058260660 | ||||||||
| FaxNumber: | 3058250245 | ||||||||
| Practice Location | |||||||||
| Address1: | 1660 SW 72ND AVE | ||||||||
| Address2: | |||||||||
| City: | PLANTATION | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333175035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3058260660 | ||||||||
| FaxNumber: | 3058250245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 12/20/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | ME802582 | FL | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | J90338900 | 05 | FL | MEDICAID |