Provider Demographics
NPI:1326040635
Name:BROBERG, PETER (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:BROBERG
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 1:4207 JAMES CASEY ST
Mailing Address - Street 2:STE 305
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-1193
Mailing Address - Country:US
Mailing Address - Phone:512-447-6096
Mailing Address - Fax:512-447-2247
Practice Address - Street 1:4207 JAMES CASEY ST
Practice Address - Street 2:STE 305
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-1193
Practice Address - Country:US
Practice Address - Phone:512-447-6096
Practice Address - Fax:512-447-2247
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF3054207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8088J0OtherBLUE CROSS BLUE SHIELD
TX114047703Medicaid
TX180037540OtherPALMETTO RR MEDICARE
TX8088J0OtherBLUE CROSS BLUE SHIELD
TX8088J0Medicare ID - Type Unspecified