Provider Demographics
NPI:1053591099
Name:MONCADO, PETER ANTHONY (DC)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:ANTHONY
Last Name:MONCADO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12439 POWAY RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064
Mailing Address - Country:US
Mailing Address - Phone:858-679-8179
Mailing Address - Fax:858-679-3793
Practice Address - Street 1:12439 POWAY RD
Practice Address - Street 2:SUITE A
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064
Practice Address - Country:US
Practice Address - Phone:858-679-8179
Practice Address - Fax:858-679-3793
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-07
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC25906111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA25906OtherLICENSE #
CAWDC25906AOtherINDIVIDUAL #
CA25906OtherLICENSE #
CAW16518Medicare PIN