Active NPI
Peter O'Fallon Jr., ATC/LAT
- Athletic Trainer
- Destin, FL
National Provider Identifier
1104200179
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Athletic Trainer
- License
- AL 4145
- Practice address
- 4421 Commons Dr E
Suite-B 108
Destin, FL 32541-3484 - Phone
- (850) 460-2588
- NPI assigned
- Jul 19, 2015
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Athletic Trainer | 2255A2300X | AL 4145 | FL | Primary |
Addresses
Primary practice location
4421 Commons Dr E
Suite-B 108
Destin, FL 32541-3484
Mailing address
93 Dune Lakes Cir
B106
Santa Rosa Beach, FL 32459-8393
Phone (314) 952-7123
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| AL 4145 | FL | MD | Athletic Trainer |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1437264000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1437264000000",
"number": "1104200179",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "93 DUNE LAKES CIR",
"address_2": "B106",
"city": "SANTA ROSA BEACH",
"state": "FL",
"postal_code": "324598393",
"telephone_number": "314-952-7123"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4421 COMMONS DR E",
"address_2": "SUITE-B 108",
"city": "DESTIN",
"state": "FL",
"postal_code": "325413484",
"telephone_number": "850-460-2588"
}
],
"practiceLocations": [],
"basic": {
"last_name": "O'FALLON",
"first_name": "PETER",
"name_prefix": "Mr.",
"name_suffix": "Jr.",
"credential": "ATC/LAT",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2015-07-19",
"last_updated": "2015-07-19",
"status": "A"
},
"taxonomies": [
{
"code": "2255A2300X",
"taxonomy_group": "",
"desc": "Specialist/Technologist, Athletic Trainer",
"state": "FL",
"license": "AL 4145",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Destin, FL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 19, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.