Provider Demographics
NPI:1922362490
Name:PETERSON, TIMOTHY (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:PETERSON
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 1:4235 SOUTHWEST BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-5635
Mailing Address - Country:US
Mailing Address - Phone:325-747-1511
Mailing Address - Fax:325-747-4108
Practice Address - Street 1:4235 SOUTHWEST BLVD
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-5635
Practice Address - Country:US
Practice Address - Phone:325-747-1511
Practice Address - Fax:325-747-4108
Is Sole Proprietor?:No
Enumeration Date:2012-06-29
Last Update Date:2025-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVLL2279207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine