Provider Demographics
NPI:1164535282
Name:PETERSON, CHRISTOPHER C (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:C
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 1:2142 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-6829
Mailing Address - Country:US
Mailing Address - Phone:325-245-4191
Mailing Address - Fax:325-245-4059
Practice Address - Street 1:2142 SUNSET DR
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-6829
Practice Address - Country:US
Practice Address - Phone:325-245-4059
Practice Address - Fax:325-245-4059
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP3789207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX314692001Medicaid
TX314692001Medicaid
TN1507497Medicaid