Provider Demographics
NPI:1730113317
Name:PETERSON, STEVEN WARREN (DO)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:WARREN
Last Name:PETERSON
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 1:1315 WATERS EDGE DR
Mailing Address - Street 2:SUITE # 107
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76048-1300
Mailing Address - Country:US
Mailing Address - Phone:817-579-5476
Mailing Address - Fax:817-579-5489
Practice Address - Street 1:1315 WATERS EDGE DR
Practice Address - Street 2:SUITE # 107
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76048-1300
Practice Address - Country:US
Practice Address - Phone:817-579-5476
Practice Address - Fax:817-579-5489
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL7110208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX219230401Medicaid
IA1254425Medicaid
H29794Medicare UPIN
IA1254425Medicaid
IA18927Medicare PIN