Provider Demographics
NPI:1184890543
Name:PETERSEN, ERIC J (MD)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:J
Last Name:PETERSEN
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 1:1550 S STAPLES ST
Mailing Address - Street 2:STE 150
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78404-3123
Mailing Address - Country:US
Mailing Address - Phone:361-800-8155
Mailing Address - Fax:361-882-2590
Practice Address - Street 1:205 E TORONTO AVE
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78503-1209
Practice Address - Country:US
Practice Address - Phone:956-687-6155
Practice Address - Fax:956-618-0451
Is Sole Proprietor?:No
Enumeration Date:2008-05-06
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX43275207Q00000X
WAMD 60036832207Q00000X
UT7333423-1205207Q00000X
WAML 20009169390200000X
TXN8336207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXN8336OtherMEDICAL LICENSE
UT7333423-1205OtherMEDICAL LICENSE
WAMD 60036832OtherWASHINGTON
WA20009169OtherMEDICAL LICENSE
UTP00764206 MCRRMedicare PIN
WAMD 60036832OtherWASHINGTON