Provider Demographics
NPI:1982643680
Name:PETERSON, TRULY (MD)
Entity Type:Individual
Prefix:
First Name:TRULY
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1506 PARKE FIELD PASS
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-3188
Mailing Address - Country:US
Mailing Address - Phone:512-569-8015
Mailing Address - Fax:512-406-6216
Practice Address - Street 1:1301 W 38TH ST #205
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1011
Practice Address - Country:US
Practice Address - Phone:512-324-1864
Practice Address - Fax:512-419-9016
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM2338207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX181423804Medicaid
TX181423803Medicaid
TX181423805Medicaid
TX181423802Medicaid
TX181423805Medicaid
TXTXB154845Medicare PIN
TXP00432686Medicare PIN
TX181423802Medicaid
TX8J1620Medicare PIN
TX8J9698Medicare PIN