Provider Demographics
NPI:1275649725
Name:STACK, PETER STEVEN (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:STEVEN
Last Name:STACK
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 1:4708 ALLIANCE BLVD STE 300
Mailing Address - Street 2:BAYLOR MEDICAL PLAZA 1
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-5339
Mailing Address - Country:US
Mailing Address - Phone:972-758-6000
Mailing Address - Fax:972-758-6001
Practice Address - Street 1:4708 ALLIANCE BLVD STE 300
Practice Address - Street 2:BAYLOR MEDICAL PLAZA 1
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-5339
Practice Address - Country:US
Practice Address - Phone:972-758-6000
Practice Address - Fax:972-758-6001
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG2577207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX114764701Medicaid
TX110097146OtherRR MEDICARE
TX8B9914Medicare ID - Type Unspecified
TX114764701Medicaid
TX83X017Medicare PIN
TX110097146OtherRR MEDICARE
TX8B9914Medicare PIN