Provider Demographics
NPI:1508977851
Name:KWONG, PETER C (MD1)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:C
Last Name:KWONG
Suffix:
Gender:M
Credentials:MD1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 CENTRAL DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76022
Mailing Address - Country:US
Mailing Address - Phone:817-399-9997
Mailing Address - Fax:817-399-0694
Practice Address - Street 1:1600 CENTRAL DR
Practice Address - Street 2:SUITE 200
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76022
Practice Address - Country:US
Practice Address - Phone:817-399-9997
Practice Address - Fax:817-399-0694
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ9144207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0154920267OtherPACIFICARE
TX2285320OtherAETNA
TX8215807004OtherCIGNA
TX008EKOtherBLUECROSSBLUESHIELD
TX113538602Medicaid
TX0154920267OtherPACIFICARE
TX00491LMedicare PIN