Provider Demographics
NPI:1518027366
Name:PETERSON, DANIEL L (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:L
Last Name:PETERSON
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 1:801 W 38TH ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705-1167
Mailing Address - Country:US
Mailing Address - Phone:512-306-1323
Mailing Address - Fax:512-306-1142
Practice Address - Street 1:801 W 38TH ST
Practice Address - Street 2:SUITE 400
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1167
Practice Address - Country:US
Practice Address - Phone:512-306-1323
Practice Address - Fax:512-306-1142
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ6207207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4599570OtherAETNA
TX120619503OtherTPI
TXP000N72D6Medicaid
TX140005923OtherMEDICARE RAILROAD
TX89732FOtherBLUE CROSS BLUE SHIELD
TX140005923OtherMEDICARE RAILROAD
TX89732FMedicare PIN