Provider Demographics
NPI:1487650420
Name:BIDWELL, PETER ALEXANDER (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:ALEXANDER
Last Name:BIDWELL
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 1:1007 DICKERSON DR
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:TX
Mailing Address - Zip Code:75951-5110
Mailing Address - Country:US
Mailing Address - Phone:409-384-3421
Mailing Address - Fax:409-384-7443
Practice Address - Street 1:1007 DICKERSON DR
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:TX
Practice Address - Zip Code:75951-5110
Practice Address - Country:US
Practice Address - Phone:409-384-3421
Practice Address - Fax:409-384-7443
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXFO386207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8AJ761OtherBCBS
TXB21264Medicare UPIN