Provider Demographics
NPI:1578564704
Name:RUTLEDGE, PETER L (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:L
Last Name:RUTLEDGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6100 HARRIS PKWY
Mailing Address - Street 2:SUITE 270
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-4101
Mailing Address - Country:US
Mailing Address - Phone:817-433-5978
Mailing Address - Fax:817-433-5980
Practice Address - Street 1:6100 HARRIS PKWY
Practice Address - Street 2:SUITE 270
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4101
Practice Address - Country:US
Practice Address - Phone:817-433-5978
Practice Address - Fax:817-433-5980
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG3749208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX033414601Medicaid
TX033414601Medicaid
TX00G06BMedicare ID - Type Unspecified