Provider Demographics
NPI:1053429753
Name:BENTZ, PETER BLACKWELL (PT)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:BLACKWELL
Last Name:BENTZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4102
Mailing Address - Country:US
Mailing Address - Phone:817-338-4220
Mailing Address - Fax:817-338-1639
Practice Address - Street 1:1109 8TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4102
Practice Address - Country:US
Practice Address - Phone:817-338-4220
Practice Address - Fax:817-338-1639
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1023109225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F0558Medicare PIN
TX650404Medicare PIN