Provider Demographics
NPI:1609842525
Name:PETERSON, ALISA GAY (DO)
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:GAY
Last Name:PETERSON
Suffix:
Gender:F
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 910042
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75391-0042
Mailing Address - Country:US
Mailing Address - Phone:972-788-1692
Mailing Address - Fax:
Practice Address - Street 1:411 N BELKNAP ST
Practice Address - Street 2:
Practice Address - City:STEPHENVILLE
Practice Address - State:TX
Practice Address - Zip Code:76401-3415
Practice Address - Country:US
Practice Address - Phone:254-965-1152
Practice Address - Fax:254-965-1156
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL7109207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F3319OtherBLUE CROSS BLUE SHIELD
TXTX6027610OtherCHAMPUS
TX161152702Medicaid
TXP00322298OtherRAILROAD MEDICARE
TXP00322298OtherRAILROAD MEDICARE
TX8F3319OtherBLUE CROSS BLUE SHIELD