Provider Demographics
NPI:1851793988
Name:PETER J DAMICO MD PA
Entity Type:Organization
Organization Name:PETER J DAMICO MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:J
Authorized Official - Last Name:DAMICO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-738-9268
Mailing Address - Street 1:6010 CURZON AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-5531
Mailing Address - Country:US
Mailing Address - Phone:817-738-9268
Mailing Address - Fax:817-738-9271
Practice Address - Street 1:6010 CURZON AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-5531
Practice Address - Country:US
Practice Address - Phone:817-738-9268
Practice Address - Fax:817-738-9271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-19
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX114601102Medicaid
TX080018812OtherRAILROAD MEDICARE
TXD87256Medicare UPIN
TX00F11FMedicare PIN