Provider Demographics
NPI:1295714798
Name:PETERSEN, KATHARINE (MD)
Entity type:Individual
Prefix:
First Name:KATHARINE
Middle Name:
Last Name:PETERSEN
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 1:7933 BRIARIDGE RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75248-5315
Mailing Address - Country:US
Mailing Address - Phone:972-661-1529
Mailing Address - Fax:
Practice Address - Street 1:7777 FOREST LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-2505
Practice Address - Country:US
Practice Address - Phone:972-566-2667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL9427207P00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX173055811OtherCSHCN
TX8S2685OtherBCBS
TX173055803Medicaid
TX173055804Medicaid
TX0033PTOtherBCBS
TX173055803Medicaid
TX173055811OtherCSHCN