Provider Demographics
NPI:1225047012
Name:MALOUF, PETER J (DO)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:J
Last Name:MALOUF
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5825 EDWARDS RANCH RD STE 201
Mailing Address - Street 2:
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-4122
Mailing Address - Country:US
Mailing Address - Phone:817-205-3075
Mailing Address - Fax:
Practice Address - Street 1:203 WALLS DR STE 100
Practice Address - Street 2:
Practice Address - City:CLEBURNE
Practice Address - State:TX
Practice Address - Zip Code:76033
Practice Address - Country:US
Practice Address - Phone:817-205-3075
Practice Address - Fax:817-641-3355
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK0518207ND0101X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX070016227OtherMEDICARE RAILROAD
TX8335B7OtherBLUE CROSS BLUE SHIELD
TX1136830-01Medicaid
TX8335B7OtherBLUE CROSS BLUE SHIELD
TX00769TMedicare ID - Type Unspecified