Provider Demographics
NPI:1225128259
Name:PITONAK, PETER (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:PITONAK
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:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6450
Mailing Address - Fax:
Practice Address - Street 1:703 E FLEISHEL AVE
Practice Address - Street 2:STE 4000
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2015
Practice Address - Country:US
Practice Address - Phone:903-606-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00024770207R00000X
TXM9934207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51511035OtherBLUE CROSS BLUE SHIELD
AL110248812OtherRAILROAD MEDICARE
AL051511035Medicaid
TX75-2616977-132OtherTRICARE
TX75-2616977-132OtherTRICARE
ALH69244Medicare UPIN