1255474219 NPI number — DR. ANTHONY PETERSON OD

Table of content: DR. ANTHONY PETERSON OD (NPI 1255474219)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255474219 NPI number — DR. ANTHONY PETERSON OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
ANTHONY
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255474219
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/13/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
150 E HIGHWAY 67
Provider Second Line Business Mailing Address:
SUITE 120
Provider Business Mailing Address City Name:
DUNCANVILLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75137-4476
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-298-3937
Provider Business Mailing Address Fax Number:
972-298-2170

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
150 E HIGHWAY 67
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
DUNCANVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75137-4476
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-298-3937
Provider Business Practice Location Address Fax Number:
972-298-2170
Provider Enumeration Date:
02/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  7032TG , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 196604604 . This is a "MEDICAID PROVIDER TPI#" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 269216 . This is a "MEDICARE PTAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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