Provider Demographics
NPI:1336432608
Name:KNICKERBOCKER, PETER FORD (DO)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:FORD
Last Name:KNICKERBOCKER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3435 GURNARD CT
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-3304
Mailing Address - Country:US
Mailing Address - Phone:215-298-2476
Mailing Address - Fax:
Practice Address - Street 1:BLDG H 2005 KNIGHT LANE
Practice Address - Street 2:NAVY MEDICINE SUPPORT COMMAND
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32212-0140
Practice Address - Country:US
Practice Address - Phone:215-298-2476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-19
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA20A124202080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program