Provider Demographics
NPI:1295794329
Name:PETERSON, DOLORES M (MD PHD)
Entity type:Individual
Prefix:
First Name:DOLORES
Middle Name:M
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MD PHD
Other - Prefix:
Other - First Name:DOLORES
Other - Middle Name:MURL
Other - Last Name:KELLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4403 SILVERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77035-3635
Mailing Address - Country:US
Mailing Address - Phone:214-912-9028
Mailing Address - Fax:
Practice Address - Street 1:4403 SILVERWOOD DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77035-3635
Practice Address - Country:US
Practice Address - Phone:214-912-9028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-18
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH3927208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX119079503Medicaid
TX119079503Medicaid
E51690Medicare UPIN