Provider Demographics
NPI:1093801276
Name:PETERSON, ERIC WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:WAYNE
Last Name:PETERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11511 SHADOW CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-7298
Mailing Address - Country:US
Mailing Address - Phone:713-442-0000
Mailing Address - Fax:
Practice Address - Street 1:11555 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77478-3889
Practice Address - Country:US
Practice Address - Phone:713-442-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ2900207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX045306004Medicaid
TX045306006Medicaid
TXTXB109697Medicare PIN
TX86X930Medicare PIN
TX045306006Medicaid
TX8257B5Medicare PIN
TX045306001Medicaid
TX8345B4Medicare PIN