Provider Demographics
NPI:1518901842
Name:PESKA, DON N (DO)
Entity Type:Individual
Prefix:
First Name:DON
Middle Name:N
Last Name:PESKA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 99335
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76199-0335
Mailing Address - Country:US
Mailing Address - Phone:817-735-5450
Mailing Address - Fax:817-735-5454
Practice Address - Street 1:855 MONTGOMERY ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-2553
Practice Address - Country:US
Practice Address - Phone:817-735-5450
Practice Address - Fax:817-735-5454
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG24542086S0129X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX115932903Medicaid
TX846873OtherBCBS
TX120002038OtherRAILROAD MEDICARE PIN
TX120002038OtherRAILROAD MEDICARE PIN
TX115932903Medicaid