Provider Demographics
NPI:1265636856
Name:VAN DELDEN, PETER ROLAND (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:ROLAND
Last Name:VAN DELDEN
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 690804
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78269-0804
Mailing Address - Country:US
Mailing Address - Phone:210-530-1235
Mailing Address - Fax:210-530-1187
Practice Address - Street 1:18007 W IH 10
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78257-9536
Practice Address - Country:US
Practice Address - Phone:210-530-1235
Practice Address - Fax:210-530-1187
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-14
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM9714207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX198439503Medicaid
2775644759OtherMYUTMB 2775644759-COMMERCIAL NUMBER
TX198439503Medicaid