Provider Demographics
NPI:1184987448
Name:EBERE, PETER
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:EBERE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 KNOLLCREST LN
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75181-2938
Mailing Address - Country:US
Mailing Address - Phone:469-831-1960
Mailing Address - Fax:972-222-6658
Practice Address - Street 1:3333 KNOLLCREST LN
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75181-2938
Practice Address - Country:US
Practice Address - Phone:469-831-1960
Practice Address - Fax:972-222-6658
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-21
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX008499172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
679464Medicare PIN