Provider Demographics
NPI:1063561934
Name:KLADSTRUP, PETER (DC)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:KLADSTRUP
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 1:565 PERINTON HILLS OFFICE PARK
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-3610
Mailing Address - Country:US
Mailing Address - Phone:585-425-3626
Mailing Address - Fax:585-425-0202
Practice Address - Street 1:565 PERINTON HILLS OFFICE PARK
Practice Address - Street 2:
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450-3610
Practice Address - Country:US
Practice Address - Phone:585-425-3626
Practice Address - Fax:585-425-0202
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6731-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY11072BMedicare ID - Type Unspecified