Provider Demographics
NPI:1073026530
Name:PETERSON, THOMAS (DC)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:PETERSON
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:PO BOX 700688
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78270-0688
Mailing Address - Country:US
Mailing Address - Phone:800-404-6050
Mailing Address - Fax:866-313-3397
Practice Address - Street 1:14688 STATE HIGHWAY 121 STE 130
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75035-4662
Practice Address - Country:US
Practice Address - Phone:800-404-6050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-07
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13523111N00000X, 111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX111N00000XOtherCHIROPRACTOR