Provider Demographics
NPI:1588840029
Name:GLENDA JEAN PETERS-DO, M.D., P.A.
Entity type:Organization
Organization Name:GLENDA JEAN PETERS-DO, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENDA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:PETERS-DO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:361-992-9300
Mailing Address - Street 1:6121 CORALRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78413-3135
Mailing Address - Country:US
Mailing Address - Phone:361-992-9300
Mailing Address - Fax:361-992-9302
Practice Address - Street 1:527 GORDON ST
Practice Address - Street 2:SUITE C
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78404-2535
Practice Address - Country:US
Practice Address - Phone:361-992-9300
Practice Address - Fax:361-992-9302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-15
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ8713207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1033135876OtherINDIV NPI
TX00570VOtherMEDICARE GROUP
TX00570VOtherMEDICARE GROUP