Provider Demographics
NPI:1922004472
Name:PETERS, THEODORE THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:THOMAS
Last Name:PETERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2535 IRA E WOODS AVENUE
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-3930
Mailing Address - Country:US
Mailing Address - Phone:817-481-2121
Mailing Address - Fax:817-488-4493
Practice Address - Street 1:2535 IRA E WOODS AVENUE
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-3930
Practice Address - Country:US
Practice Address - Phone:817-481-2121
Practice Address - Fax:817-488-4493
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF4371207X00000X, 207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX099325501Medicaid
TX82X722OtherBLUE CROSS BLUE SHIELD
TX82X722OtherBLUE CROSS BLUE SHIELD
TX099325501Medicaid
TXD35127Medicare UPIN
TX099325501Medicaid