Provider Demographics
NPI:1205837432
Name:WOLLAN, PETER T (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:T
Last Name:WOLLAN
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 1:5011 BURNET RD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78756-2611
Mailing Address - Country:US
Mailing Address - Phone:512-583-2020
Mailing Address - Fax:512-744-2020
Practice Address - Street 1:5011 BURNET RD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78756-2611
Practice Address - Country:US
Practice Address - Phone:512-583-2020
Practice Address - Fax:512-744-2020
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM0975207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX173163001Medicaid
8M5286OtherBLUE CROSS
TX173163001Medicaid
8E0448Medicare ID - Type Unspecified
I27743Medicare UPIN